Monterey Bay Institute of Electrology
351 Kolb Avenue
Monterey, CA 93940
1-831-643-2100
APPLICATION FOR ENROLLMENT
Select Salutation: ( ) Mr. ( )Mrs. ( )Miss ( ) Ms. ( ) Other __________
Name: ____________________________________________________ Birth Date: ______________________
Social Security #: ______________________ Driver's License: _________________ State:______ Exp: ______
Home Phone # (______)________________________ Cell/Other # (______)___________________________
Current Address: ____________________________________ City______________ State: _____ Zip: _______
Permanent
Address: ___________________________________________City: _____________ State: _____ Zip: _______
EDUCATION:
High School/City,St: _______________________________________________ Year Graduated or GED ______
College/Other: _______________________________________________________________________________
WORK EXPERIENCE & DUTIES: Please attach resume.
PERSONAL REFERENCES:
Name Address Phone #___________________
1. _________________________________________________________________________________________
2. _________________________________________________________________________________________
3. _________________________________________________________________________________________
IN CASE OF EMERGENCY:
Name Address Phone #___________________
1. _________________________________________________________________________________________
2. _________________________________________________________________________________________
Hobbies & Interests: ___________________________________________________________________________
Why are you interested in the Field of Electrology? __________________________________________________
How were you referred to the Monterey Bay Institute of Electrology? ____________________________________
Signature: ________________________________ Date: ________________ Proposed Start Date: ____________
Attach a check for $75 (nonrefundable application fee) made out to MBIE and mail it with this application to:
Monterey Bay Institute of Electrology, Attn: Randa Thurman, LE, CPE, Director at the address above.