Application Form = Summer 2019 Personal Information General Information 111. Title (Ms, Mrs, other) MS. 141. Company or Place of study LSJ Dental LW 112. First Name(s) / Given Name(s) Karyna 142. Sector or Major General Dentistry 113. Last Name(s) / Sumamefs) Shuliak 143. Job Title or Student Dentist 114. Father's Fist & Last Name(s) Fedor Chouliak Passport 121. Date of Birth (DD/MM/YYYYI 122. Place of Birth 123. Nationaitylies) United States of America 124. Passport # 125. Issued by (Country' USA 126. Vold From (DD/MM/YYYY) 13/06/2018 127. Vold Until (DD/MM/YYYY1 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 gNo al giLii_A"i gn ii qfir General 146. Who recommended IVP? How did you find IVP? Ariane Rothschild 147. What do you hope to gain from the course? The ability to hold salons in New York 131. Mobile # (includinq country code Which one(s) 8 Where? 132. E-mail 133. Facebook 134. Twitter Mailing Address fr I SI. Title Ms. 152. First Nomefs)/ Given name(s) Karyna 153. Last Name(s)/ Sumame(s) Shuliak Select to copy info from "Personal Information" 154. Company 155. 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 # (including country code) 162. E-mad or Fax # karynashuliak@icloucLcom 149. Do you work for the media press, TV, ...) 0 Yes 21 No, which one? Billing Address (if different from Mailing Address) 171. Title 172. Fist Name(s)/ Given name(s) 173. Last Name(s)/ Sumame(s) 174. Company 175. Position 176. Full Address 177. City, Zip Code, State I78. Country 181. Direct Tel# (including country code] 182. E-mail or Fax # 11 PDFfIller Document ID: 6305-0DB5-8336-0006 0 2019.06-CS V 1O EN VN-pn Rev: 2018.09-24 EFTA00521677