Certified Phlebotomy Technician (Discount)
Course Registration Form (non-refundable registration fee required)
Name
*
First Name
Last Name
E-mail
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Number
*
Please enter a valid phone number.
Emergency Contact
*
First Name
Last Name
High School Attended
*
Graduation/GED Year
*
-
Month
-
Day
Year
Date
How Did You Hear About Us?
*
Facebook
Google
Instagram
A friend
Other
Choose Class Schedule
Morning Mon/Wed (November 3rd)
Night Mon/Wed (November 3rd)
Payment
Payment Options
*
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next
( X )
Discounted Tuition (total)
$
1,550.00
Non-Refundable Registration Fee (Payment plan)
By choosing this option, you will have 4 remaining payments to complete on a Bi-weekly basis via automatic invoice.
$
450.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Submit
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