WPD 012 Certified Medical Coder Training Application

WCCC Certified Medical Coder

Training Application
Thank you for your application for the Certified Medical Coder Program. The program has met capacity, all received applications will be placed on a waitlist for potential future offerings of the program.
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
E-mail*
Are you a resident of Maine?*

YesNo
County of residence?
Are you a US citizen?*

YesNo
If no, are you legally entitled to work in the United States?

YesNo
Ethnic Group*

Not Hispanic/LatinoHispanic/Latino
Race*

American Indian or Alaska NativeAsianBlack or African AmericanWhiteNative Hawaiian or Other Pacific Islander
Gender*

MaleFemaleOther
How did you hear about this training program?

NewspaperEmail NewsletterFacebookWord of MouthOther
Education (highest grade completed)*

No HS CompletionHS Diploma, GED, or HiSetSome college/no credentialCredential < 2 year or Associate degreeAssociate's degreeBachelor's degreeMaster's degree of higher
Are you currently employed?*

YesNo
If yes, who is your employer?
If employed, do you work full-time? *
Have you been negatively economically affected y Covid 19?

YesNo
Is someone else covering the cost of the course for you?

YesNo
I certify that all information on this application is accurate and complete.
Signature

Clear
Should be Empty:

WCCC Certified Medical Coder