Manhattan Institute Medical and Nurse Career School New York NY

Course Application Form

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Application for Admission		Data on this form is security encrypted and sent to admissions, maintaining your privacy and security at all times
Name*		Address*
City*		State*
Zip Code*	Note:If zip code in 3 or 4 digit then add zero before the zip code(Eg:00zipcode)	Home Telephone*	(Eg: xxx-xxx-xxxx)
Cell Phone	(Eg: xxx-xxx-xxxx)	Birth Date(mm/dd/yyyy)*
Email*		How did you learn about Manhattan Institute?*
Educational Background (A High School Diploma or GED is only needed for our Medical Assistant Class.)
High School Attended	Yes No	High School
Address
Did you graduate?	Yes No	If yes, date graduated(mm/dd/yyyy)?
Do you have a G.E.D.?	Yes No	Date Received(mm/dd/yyyy)
State		Have you ever attended any other school?	Yes No
Name and location of school
Current Employment Information
Are you working Now?	Yes No
Name of company		Years there
Address		Your position
Work Telephone
Classes and Pricing (financing is available)*
Phlebotomy Technician $799.00	Medical Biller $699.00	Certified Nurse's Aid $1499.00	Pharmacy Technician $1399.00
EKG Technician $799.00	Patient Care Technician $1399.00	Medical Assistant $11,999.00	Dialysis Tech $1799.00
Choose Phlebotomy Technician and EKG Technician together and save $200! Phlebotomy and EKG Combo: $1399
Section*
I wish to attend classes:	During the day During the evening On the weekend
Security Code
	Please enter security Code below in given text box.
Security Code*

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