WPD 012 Certified Medical Coder Training Application

WPD 012 Certified Medical Coder Training Application

WCCC Certified Medical Coder

Training Application
Thank you for your application for the Certified Medical Coder 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?
County of residence?
Are you a US citizen?
If no, are you legally entitled to work in the United States?
Ethnic Group
Race
Gender
How did you hear about this training program?

Other
Education (highest grade completed)
Are you currently employed?
If yes, who is your employer?
If employed, do you work full-time?
Have you been negatively economically affected y Covid 19?
Is someone else covering the cost of the course for you?
I certify that all information on this application is accurate and complete.
Signature
Should be Empty: