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Medical Esthetic Certification Application E.T. S. - Plaza 51, 444 Brickell Avenue, Suite 413, Miami, Florida 33131, USA M&EA, Intl.– 4801 Linton Blvd., #11A-632, Delray Beach, Florida 33445-6582 - Application Form for 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 for non-M&EA students.
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 – 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&EA students only need application items listed in bold, non-M&EA students - all items are required with application fee) Note- Exam for Level II is only 350 multi choice and True/False question, Non-level II has additional exam parts, including skin charts and treatments written out. Non-level II attendees must allow for additional time on the exam. M&EA students: Medical & Esthetic Associates, Intl. (exam) Enclose appl. with $295.00 4801 Linton Blvd., #11A-632 Exam Fee to: Delray Beach, Florida 33445-6582 USA
___ Complete and sign this application form. ___ Enclose copies of certifications, degrees, and licenses –state license *Note- product training classes are not valid certification programs ___ Enclose one reference from Medical/Esthetic professional or M&EA Educator (may be required determined by yrs experience- or if under 5 yrs. please provide is box is checked) ___ Enclose copy of M&EA approved training certificate, if over one year past completion – (M&EA student is one who has completed an approved M&EA class or workshop from any of our approved educators in Medical Esthetics subject) (Non-level II attendees only) ___ 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-level II attendees only - practitioners with 8+yrs. experience) Please send materials Intl. Council of Education/ E.T.S. and Check/M.O. to ETS for Plaza 51, 444 Brickell Avenue, Suite 413 $75.00 application fee to: Miami, FL 33131 USA
Fees: National Certification Exam $295.00 + additional $75.00 (for non-M&EA students)- application fee, checks or money orders only to ETS on application fee (non-refundable)
$295.00 Exam fee Visa, MC/Am Exp# ______________________________________________________ Exp. __________________________ Security code (on back) __________________ Total amount to be charged $ _________________________ Signature ________________________________________ Date: _________________
M&EA Students may fax this application and fee to: 1-312-896-7444
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