<p> Northern Tier Career Center 120 Career Center Lane Towanda, PA 18848 (570) 265-8111 Fax: (570) 265-3002 www.ntccschool.org</p><p>Cosmetology Program</p><p>APPLICATION FOR ENROLLMENT</p><p>1. Name ______Social Security Number ______</p><p>2. Address ______</p><p>3. Telephone Number ______Veteran? Y or N 35 or older? Y or N</p><p>4. I have completed a ninth grade education or the equivalent thereof. Yes or No (A notarized letter from your school must accompany this application) Waived for Veterans or those 35 or older. ( Proof must be submitted)</p><p>5. ___ I AM or ____ AM NOT transferring hours from another school of cosmetology. ( A notarized certificate of transfer must accompany this application)</p><p>6. PHYSICIAN AFFIDAVIT (Must be completed by examinating physician)</p><p>Commonwealth of Pennsylvania County of ______I, a licensed and registered physician, Physician’s Signature under the laws of the Commonwealth of ______Pennsylvania, have examined ______Physician’s Printed Name ______and find ______her/him to be free of infectious ______diseases. ______Physician’s Registration No. Date ______</p><p>______</p><p>7. APPLICATION AFFIDAVIT (must be signed by applicant in the presence of notary public) Commonwealth of Pennsylvania, County of ______I, ______, being Applicant’s signature</p><p>The Northern Tier Career Center is an equal opportunity education institution and will not discriminate on the basis of race, color, national origin, sex or handicap in its activities, programs or employment practices as required by Title VI and IX and Section 504. For more information, contact the Title IX and Section 504 Coordinator at 120 Career Center Lane Towanda, PA 18848-8095, (570) 265-8111. Duly sworn, do depose and say that I am the person making the foregoing application, Subscribed and sworn to before that I have read all the items therein care- me this ______day of fully, and that all the statements made 20______. therein are true to the best of my know- ______ledge and belief. (Notary Public) My Commission expires ____</p><p>______Signature of School Official Date</p><p>The Northern Tier Career Center is an equal opportunity education institution and will not discriminate on the basis of race, color, national origin, sex or handicap in its activities, programs or employment practices as required by Title VI and IX and Section 504. For more information, contact the Title IX and Section 504 Coordinator at 120 Career Center Lane Towanda, PA 18848-8095, (570) 265-8111.</p>