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Application Form for CAMS/ CMES

Complementary Healthcare Certification

Medical Esthetic Certification Application

E.T. S. - 1835 N.E. Miami Gardens Drive, Suite 201 - North Miami, Florida, 33179 - U.S.A

M & E Intl.Assoc.– Secure Box 1409, Boca Raton, Florida 33429-1409

Application Form for Complementary Healthcare CAMS, CMES

Please type or print all the information.

Please use an extra sheet of paper for more writing space.

This application is not a guarantee for acceptance.

Name___________________________ M _ F ___

Address ________________________________________________________________

City _________________________ State ______ Zip _________ Country _________

Work Phone _________________________ Home Phone ________________________

Fax Number _________________________ Cell Phone __________________________

Email ______________________________ Home page _________________________

Date of Birth ________________ Marital Status ______________ SSN _____________

Is English your main language? Yes ___ No ___

If not, please describe how fluent you are in English (TOEFL scores may be required):

________________________________________________________________________

Did anyone refer you to us and who? _________________________________________

If not how did you hear about us? ____________________________________________

Which program are you applying for? Please mark one:

___ AMS MediEsthetic Specialist™ – Aesthetic Medical Specialist™ - Aesthetician, RN, LPN/LVN, Medical Assistant, Esthetic Professional (all professionals who must work under the supervision of a Physician – in some states this may include PA’s)

___ MES Medical Esthetic Specialist™ – Nurse Practitioner, Physician Assistant

___ MES Medical Esthetic Specialist™ - Licensed Health Professionals such as

NMD, ND, MD, DO, DDS, DC, DVM, DOM, PhD, etc.

List all schools and colleges you have attended: (Medical, Esthetic or Collage)

Name of school Major Date started and finished Degree earned

___________________ ________ _____________________ ____________

What current certifications and credentials do you have?

________________________________________________________________________

What licenses do you hold and what is their status? (Please give state, license number and expiration date.) Enclosed a copy of current state license- (not required for many countries)

________________________________________________________________________

In which professional associations do you hold membership?

________________________________________________________________________

What life experiences, including paid and voluntary jobs, do you have that may relate to Medical Esthetics?

________________________________________________________________________

What are your expectations of this program?

______________________________________________________________________

________________________________________________________________________

What are your goals after completing the program?

________________________________________________________________________

Do you have any felony convictions, had any disciplinary actions or have any pending litigation in any state? Yes ____ No ____

Have you ever been a defendant in a legal action involving professional liability such as malpractice? Yes ____ No ____

Have any of your licenses ever been revoked, or has any disciplinary action been taken on any of your licenses in any state? Yes ____ No ____

Has any authority or peer review board taken adverse action against any license or certification privilege, or are you currently under investigation by any authority or peer review board for any violation of any state or country, federal or local law, or has any authority or peer review board informed you of any pending charges not reported to the review board? Yes____ No_____

Have you been terminated or asked to resign from employment since obtaining your license (esthetic or medical)? Yes ____ No ____

If yes on one of the above three questions, please explain on a separate sheet of paper.

State or country in which you are practicing, or plan to practice? ___________________

Do you have any physical or mental disabilities or affections which might affect your ability to function as a MediEsthetic or Medical Esthetic Specialist? Yes ____ No ____

Internship /Advanced Study: Location: ________________________________________

Do you carry liability insurance? Yes ____ No ____

Insurance Agency carrying policy____________________________________________

Date Desired for Exam ______________________, City __________________________

I, ____________________________, attest that all of the above answers are true to my best knowledge and that I am aware that falsification of my records may carry consequences. If I am accepted into the program, I promise to work honestly and do all my assignments to the best of my ability. I understand and confirm I am practicing under my state license and within my scope of practice.

Signature ______________________________________ Date ____________________

Application check list:

Note - (M & E Assoc. students only need application items listed in bold, non-M & E Assoc. students - all items are required with application fee)

Note- Exam for non-M & E Assoc. students has an additional test booklet and must allow an additional hour for exam time.

M & E Assoc. students: Medical & Esthetic Intl. Assoc. (exam)

Enclose appl. with $295.00 Secure Box 1409

Exam Fee to: Boca Raton, Florida 33429-1409 USA

___ Complete and sign this application form.

___ State license #__________________________________________

*Note- product training classes are not valid certification programs

___ Date and location of M-E Int’l approved training _____________________________

(M-E Int’l student is one who has completed an approved M-E Int’l class or workshop from any of our approved educators)

(Non-M&E Assoc students only) allow 4-6 weeks for processing of application

___ Enclose a check of $75 as a non-refundable application fee, payable to E.T.S.

___ Have official transcripts sent directly to E.T.S. - include esthetic and/ or medical school or BS or BA transcripts.

___ Enclose one passport type picture.

___ if applicable, include TOEFL scores, which may be required for applicants with English as a second language.

___ Enclose one letter of recommendation and two references from professionals in the Medical/Esthetic field.

(Non-M&E Int’l Assoc. Students only - practitioners with 8+yrs. experience)

Please send materials Intl. Council of Education/ E.T.S.

and Check/M.O. to ETS 1835 N.E. Miami Gardens Drive, Suite 201

$75.00 application fee to North Miami, Florida, 33179 - U.S.A

Fees: National Certification Exam $295.00 + additional $75.00 (for non-M&E Int’l Assoc. students)- application fee, checks or money orders only to ETS on application fee (non-refundable)

$295.00 Exam fee is the same for M-E Int’l students and non-students – additional proctor fees apply for non-students

Visa, MC/Am Exp# ____________________________________________________________

Exp. __________________________ Security code (on back) ________________________

Total amount to be charged $ ___________________________________________________

CC billing address______________________________________________________________

______________________________________________________________________________

Signature ________________________________________ Date: _______________________

M&E Int'l Assoc. students send application to our office for rush processing then forwarded with your class documents to ETS for exam approval- thanks!

Note - non-refundable fee

Optional Complementary Healthcare Safety Registration Cert.

Name_____________________________ M ___ F ___

Did anyone refer you to us and who? _________________________________________

If not how did you hear about us? ____________________________________________

Name___________________________ M _ F ___