Excel Medical Training
EKG Class Registration Form
Your Name:
*
First Name
Last Name
Email Address: (Gmail preferred)
*
Email
SSN:
*
example: 123-25-9870
Date of Birth
*
-
Month
-
Day
Year
MM-DD-YYYY
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
-
Area Code
Phone Number
High School:
*
Name of School
GED/Dipolma
*
Yes
No
still enrolled in High School
Year of GED/Diploma completion
*
Year
Phone Number
*
-
Area Code
Phone Number
Start Date
*
December 13, 2021
December 28, 2021
Do you have access to a computer, laptop, or Mobile phone to receive and complete assigned coursework?
*
Yes
No
How did you hear about Excel Medical Training Center?
*
Facebook
Instagram
Indeed
Google
Referral
Security Deposit
*
prev
next
( X )
Security Deposit
$
50.00
Three-Day Cancellation: An applicant who provides written notice of cancellation within three (3) business days, excluding weekends and holidays, of executing the enrollment agreement is entitled to a refund of all monies paid, excluding the $150 non-refundable registration fee.
Total
$
0.00
Credit Card
Submit File(s)
Should be Empty: