Facility Registration for Invoice

Facility Invoice for Registration

Fill out the following form if you would like to be invoiced for any student(s) you are registering.
*Important note: If you are registering students for a CMA or CNA class in Kansas, please have specific course information ready. (i.e., Course Approval Number and/or Clinical Site Location) If you do not have a specific course DO NOT fill out the form below, please use this link: Click Here
Facility Information
Your Name *

First Name Last Name
Facility Name *
Your Email Address *
example@example.com
Your Phone Number *
Please enter a valid phone number.
Has your facility received an invoice from We Care Online in the past? *

Yes No
Accounts Payable Contact Name *

First Name Last Name
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Tax ID Number *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Student Information

You will need the student's name, email and phone number. Depending on the course, you may be required to submit the student's Social Security Number, license or certification number, and address
Student Name *

First Name Last Name
Course *
KDADS Approval Number
Clinical Location Site
Which class date? *
Location of state exam *
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Date of Birth *

Month Day Year
Date
Social Security Number *
Certification or License Number *
Gender *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Would you like to add another student? *

Yes No
Student Name *

First Name Last Name
Email *
example@example.com
Course *
KDADS Approval Number
Clinical Location Site
Which class date? *
Where would the student take the state exam? *
Phone Number *
Please enter a valid phone number.
Date of Birth *

Month Day Year
Date
Social Security Number *
Certification or License Number *
Gender *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Would you like to add another student? *

Yes No
Student Name *

First Name Last Name
Email *
example@example.com
Course *
KDADS Approval Number
Clinical Location Site
Which class date? *
Where would the student take the state exam? *
Phone Number *
Please enter a valid phone number.
Date of Birth *

Month Day Year
Date
Social Security Number *
Certification or License Number *
Gender *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Would you like to add another student? *

Yes No
Student Name *

First Name Last Name
Email *
example@example.com
Course *
KDADS Approval Number
Clinical Location Site
Which class date? *
Where would the student take the state exam? *
Phone Number *
Please enter a valid phone number.
Date of Birth *

Month Day Year
Date
Social Security Number *
Certification or License Number *
Gender *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Would you like to add another student? *

Yes No
Student Name *

First Name Last Name
Email *
example@example.com
Course *
KDADS Approval Number
Clinical Location Site
Which class date? *
Where would the student take the state exam? *
Phone Number *
Please enter a valid phone number.
Date of Birth *

Month Day Year
Date
Social Security Number *
Certification or License Number *
Gender *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Would you like to add another student? *

Yes No
Student Name *

First Name Last Name
Email *
example@example.com
Course *
KDADS Approval Number
Clinical Location Site
Which class date? *
Where would the student take the state exam? *
Phone Number *
Please enter a valid phone number.
Date of Birth *

Month Day Year
Date
Social Security Number *
Certification or License Number *
Gender *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Should be Empty:

Facility Invoice for Registration

Facility Information

Student Information