Ava Enrollment Form

Select your course and date *

Individual Training Cost: $1100.00

Patient Care Technician Training Cost: $4500.00

Medical Assistant Training Cost: $6900.00

Name *

First Name Last Name

Phone Number *

Area Code Phone Number

Date of Birth *

Date

Email *

example@example.com

Note: If you choose Down payment today, the remaining payments should be made in the office. You can establish a weekly or biweekly payment plan for the remaining amount due.

My Products *

Individual Training - Pay in Full $ 1,100.00

Individual Training - Down Payment $ 400.00

7 consecutive weekly payments of $100.00 3 consecutive bi-weekly payments of $200,$200 and $300.00

Patient Care Technician Training - Pay In Full $ 4,500.00

Patient Care Technician Training - Down Payment $ 500.00

32 consecutive weekly payments of $125.00 16 consecutive by-weekly payments of $250.00

Medical Assistant Training - Pay in Full $ 6,900.00

Medial Assistant - Down Payment $ 1,000.00

45 consecutive weekly payments of $130 23 consecutive by-weekly payments of $260.00

Total $ 0.00

Credit/Debit Card Payment
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

How would you want to make the remaining payments (Fill only if you don't pay in full)

Which day of the week would you prefer your remaining payments to be charged (Fill only if you don't pay in full)

How did you hear about us?

Student signature *

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