PHCT SCHOOL
Certified to Operate by SCHEV
ONLINE PAYMENT FORM
Student Name
*
First Name
Last Name
Student Code
(Optional)
Phone Number
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Email
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Course/Program
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Please Select
AHA-BLS PROVIDER
BLS HEART CODE/HANDS-ON
CPR/FIRST AID-HEART SAVER
Medical Assistant (CCMA)
Phlebotomy Technician (CPT)
EKG Technician(CET)
Nurse Aide (NA)
Medication Management (MM)
Personal Care Aide (PCA)
Medication Aid (MA)
Date
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Month
-
Day
Year
Payment Date
Amount ($)
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USD
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Student Signature
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First Name
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Security Code
Card Expiration
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