WPD 015 Certified Medical Insurance Specialist

WCCC Certified Medical Insurance Specialist

Training Application
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
Are you a resident of Maine?*

YesNo
E-mail*
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)*

Less than high schoolHS 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 so, who is your employer?
Have you been negatively economically affected by Covid-19?

YesNp
Will someone else being paying for this course?

YesNo
If yes, who will be paying for the course?
I certify that all information on this application is accurate and complete.
Signature

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WCCC Certified Medical Insurance Specialist