CERTIFIED PHLEBOTOMY TECHNICIAN STUDENT APPLICATION
Visionary Health Career Training Institute LLC
Thank you for your expressed interest in Visionary Health Career Training Institute LLC. Fill out the form below.
VHCTI Student Application form
Program Applying For
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Please Select
Certified Phlebotomy Technician Training (In-Person)
Preferred Start Date
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Month
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Day
Year
Date
Name
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First Name
Middle Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Social Security No.
Address
Street Address
Street Address Line 2
City
State / Province
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Are you 18 years of age or older?
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Yes
No
Are you a citizen of the United States?
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Yes
No
If no, are you authorized to work in the U.S?
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Yes
No
Have you ever applied to Visionary Health Career Training Institute?
Yes
No
Have you ever been a Phlebotomist?
Yes
No
Have you ever been convicted of a felony?
Yes
No
If convicted, please explain
Education
High School
High School Address
High School Start Date
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Month
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Day
Year
Date
High School End Date
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Day
Year
Date
Did you graduate high school?
Yes
No
Do you have a high school diploma or GED?
Diploma
GED
College
College
College Address
College Start Date
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Month
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Day
Year
Date
College End Date
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Year
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Degree type
Associate
Bachelors
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Did you graduate college?
Yes
No
Other
Other Education
Other Education Address
Other Education Start Date
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Day
Year
Date
Other Education End Date
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Month
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Did you graduate from Other Education?
Yes
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Other Education Degree
References
Reference #1
Full Name
First Name
Last Name
Relationship
Company
Phone Number
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Address
Street Address
Street Address Line 2
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Reference #2
Full Name
First Name
Last Name
Relationship
Company
Phone Number
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reference #3
Full Name
First Name
Last Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employment History
List your jobs (Up to the last 3)
Employer Name
Phone Number
Please enter a valid phone number.
Supervisor
Address
Street Address
Street Address Line 2
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State / Province
Postal / Zip Code
Job Title
Responsibilities
Starting Salary
Ending Salary
From
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Month
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Day
Year
Date
To
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Month
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Day
Year
Date
Reason for Leaving
May We Contact Supervisor?
Yes
No
Employer #2
Employer Name
Phone Number
Please enter a valid phone number.
Supervisor
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Responsibilities
Starting Salary
Ending Salary
From
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Month
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Day
Year
Date
To
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Month
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Day
Year
Date
Reason for Leaving
May We Contact Supervisor?
Yes
No
Employer #3
Employer Name
Phone Number
Please enter a valid phone number.
Supervisor
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Responsibilities
Starting Salary
Ending Salary
From
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Month
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Day
Year
Date
To
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Month
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Day
Year
Date
Reason for Leaving
May We Contact Supervisor?
Yes
No
Military Service
Branch
Rank At Discharge
To
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Month
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Day
Year
Date
From
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Month
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Day
Year
Date
Type Of Discharge
If Other Than Honorable, Explain
Select Your Program
Choose your payment option below:
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CERTIFIED PHLEBOTOMY TECHNICIAN TRAINING IN-PERSON CLASS
This is an 8-week class at Main Campus. The Phlebotomy class consists of an IN-PERSON classroom and lab skills. It is non-refundable after 72 hours of application submission.
$
1,245.00
Payment Options
Pay in full (application fee $150 & tuition $1,095)
Pay partial (application fee $150 & tuition deposit $475)
Pay remaining tuition balance ($620)
Pay via Denefits Financing
Credit Card Details
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Last Name
Credit Card Number
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Card Expiration
Payment Options & Authorization
Check the box to acknowledge:
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Payment will be processed based on your chosen payment option above. You will be responsible for the immediate payment of the total amount, including the application fee. For the remaining balance, you will receive weekly invoices via email. The full remaining balance must be paid two week BEFORE the final exam.
Check the box to acknowledge:
*
A criminal background check may be required.
Disclaimer and Signature
If this application leads to acceptance to Visionary Health Career Training Institute, LLC, I understand that false or misleading information in my application may result in dismissal from the program.
I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS AUTHORIZATION IS TRUE, CORRECT AND COMPLETE.
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