Certified Phlebotomy Technician
Course Registration Form (non-refundable registration fee required)
Name
*
First Name
Last Name
E-mail
*
example@example.com
Date of Birth
*
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Month
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Day
Year
Date
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
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Emergency Contact Number
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Please enter a valid phone number.
Emergency Contact
*
First Name
Last Name
High School Attended
*
Graduation/GED Year
*
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Month
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Year
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How Did You Hear About Us?
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Choose Class Schedule
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Payment
Payment Options
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Full Tuition *promotional price*
$
1,450.00
Non-Refundable Registration Fee
$
350.00
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.
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