Application for Admission |
Data on this form is security encrypted and sent to admissions, maintaining your privacy and security at all times |
| Name |
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Address |
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| City |
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State |
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| Zip Code |
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Home Telephone |
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| Cell Phone |
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Birth Date(mm/dd/yyyy) |
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| Email |
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HOW DID YOU LEARN ABOUT THE INSTITUTE? |
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Educational Background |
| High School Attended |
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Address |
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| Did you graduate? |
Yes No |
If yes, date graduated(mm/dd/yyyy)? |
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| Do you have a G.E.D.? |
Yes No |
Date Received(mm/dd/yyyy) |
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| State |
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Have you ever attended any other school? |
Yes No |
| Name and location of school |
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Current Employment Information |
| Are you working Now? |
Yes No |
Name of company |
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| Address |
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Years there |
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| Work Telephone |
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Your position |
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| Your hours |
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Classes and Pricing (financing is available) |
| Phlebotomy Technician $549.00 |
Medical Biller $449.00 |
Certified Nurse's Aid $999.00 |
PharmacyTechnician $999.00 |
| EKG Technician $499.00 |
Patient Care Technician $949.00 |
Medical Assistant $4500.00 |
Dialysis Tech $1195.00 |
| Phlebotomy and EKG Combo $949.00 (save $100) |
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Section |
| I wish to attend classes: |
During the day |
During the evening |
On the weekend |
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