Applicant Information - Zoom Insurance

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Applicant Information (Step 1 of 4)

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Fields marked with an asterisk (*) are required.

Applicant

Applicant First Name:

Applicant Last Name:

Contact Information

Phone Number 1:	*	Phone Number 2:	*
Fax Number:	*
Email Address:	*	Confirm Email:	*

Mailing Address

Mailing Address 1:	*	Mailing Address 2:	*
City:	*
State:	*
Zip Code:	*

Trade or Service

(Please check all that apply.)

Beauty Category

Barber

Cosmetologist

Hair Stylist

Makeup Artist (non-permanent)

Nail Technician

Spa Technician

Esthetician Category

Esthetician

Trade or Service Details

Description of Trade or Service:	*
Location(s) of Trade or Service (please list all addresses):	*

Practitioner Level

What is your practitioner level?	* Professional Student
Years of Experience (please round up):	*

For Questions: Zoom Insurance
contact@zoominsurance.com


* Please upload your license(s) below:
License File #1
License File #2
License File #3
License File #4
License File #5
Please note that if you do not have a virtual copy of your license(s), you may also upload a picture of your license taken with your camera or smart phone. Accepted file upload types: GIF, JPG, JPEG, TIFF, PDF. The maximum size for uploaded files is 15 MB.