Application Form Summer 2019 Personal Information General Information 111. Title (Ms, Mrs, other) Ms. 141. Company or Place of study 112. First Name(s) / Given Name(s) Karyna 113. Last Name(s) / Sumamefs) Shuliak 114. Father's Fist & Last Name(s) Fedor Chouliak 142. Sector or Major 143. Job Title or Student Dentist 144. Religion Passport General 121. Date of Birth (DD/MM/YYYYI 146. Who recommended IVP? How did you find IVP? 122. Place of Birth Ariane Rothschild 123. Nationa ies United States of America 12tir sa l==l 125. Issued by (Country) USA 147. What do you hope to gain from the course? 126. Vold From (DD/MMIYYYY) 13/06/2018 127. Vold Until (DD/MM/YYYY) 12/06/2028 128. Schengen visa: g I don't need a visa 0 I have a valid visa 0 I will need an attestation for the visa Communication 148. Have you already attended any Etiquette courses? 0 Yes SNo The ability to hold salons in New York 131. Mobile l (including country code) Which one(s) 8 Where? 132. E-mail 133. Facebook 134. Twitter 149. Do you work for the media (press. TV, ...) 0 Yes ar No, which one? Mailing Address 151. Title Ms. 152. First Name(s)/ Given name(s) Karyna 153. Last Name(s)/ Sumame(s) Shuliak Select to copy info from "Personal Informolion" Billing Address (if different from Mailing Address) 171. Title 172. Fist Name(s)/ Given name(s) 173. Last Name(s)/ Sumame(s) 154. Company 174. Company 155. Position 175. Position 156. Full Address 6100 Red Hook Quarters, suite B-3 157. City, Zip Code, State St.Thomas, VI 00802 158. Country USA 161. Direct Tel it (including country code] 162. E-mad or Fax # 176. Full Address 177. City, Zip Code, State 178. Country 181. Direct Tell (including country code] 182. E-mail or Fax # 11 PDFflller Document ID: 6305-0DB543336-0006 0 2019-06-CS V 1O EN VN-pn Rev: 201009-24 EFTA00521673