Application Form (please print and mail this form)


Cindy's Canine Companion's Dog Grooming Salon and Services
12 Chestnut St. Box 75
Rehrersburg, Pa 19550
Phone:717-933-1333

Name: ______________________________________________________

Address: ____________________________________________________

Telephone: ________________Email Address: _____________________

Cell Phone: _________________________


Education: My highest level of education completed is: (check one)

Elementary School ______
Secondary School  ______
College                  ______


Experience:

Outline your reasons for wanting to become a Groomer:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________



Medical History:

Allergies:      Yes____No____

Diabetes:      Yes____No____

Epilepsy:      Yes____No____

Heart Condition:     Yes____No____

High Blood Pressure: Yes____No____

Impaired Vision:     Yes____No____

Medications:         Yes____No____



Size Shirt (Check one)   Sm___   Med___   Large___   X-lg___


Right handed or left handed? (Circle one)


Type of Program interested in:

___  5 week program

___  10 week, Monday thru Friday 9am-1pm, 1-5pm or 6-10pm, or 9-5pm,

___  Customized schedule



Can we use your name as a reference upon completion of sessions?______