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CHANGE REQUEST FORM
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1
Change Disclaimer
*
This field is required.
I understand that any and all changes are subject to approval. I understand that this is not confirmation of any changes, and just a request for a change. You will be notified whether your requested is approved or denied within 4 working days. Availability is subject to availability at the time the request is reviewed. I understand that if I do not show up or are late for my retest appointment I will loose my $50 payment and will have to reschedule my appointment
I agree
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2
Name
*
This field is required.
First Name
Last Name
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3
Student's Phone Number
*
This field is required.
Please enter a valid phone number.
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4
Parent's Phone Number
*
This field is required.
If 18 or older please just enter 000-000-0000
Please enter a valid phone number.
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5
Email
*
This field is required.
example@example.com
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6
What location did you attend class?
*
This field is required.
Please Select
Metairie
Norco
Laplace
Lutcher
Please Select
Please Select
Metairie
Norco
Laplace
Lutcher
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7
What age range are you in?
*
This field is required.
Please Select
17 or Younger
18 or Older
Please Select
Please Select
17 or Younger
18 or Older
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8
When did you attend class?
*
This field is required.
If 17 or younger select the first day of class.
-
Date
Year
Month
Day
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9
Please provide any notes if needed.
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10
My Products
*
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My Bag
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My Bag
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Great Product Name
$20
Quantity:
1
Size:
Small
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Great Product Name
$20
Quantity:
1
Size:
Small
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Great Product Name
$20
Quantity:
1
Size:
Small
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Great Product Name
$20
Quantity:
1
Size:
Small
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ORDER SUMMARY
Total cost
USD
Test Retake Fee
Fee must be paid to reschedule class.
$
50.00
+
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