CERTIFIED PHLEBOTOMY TECHNICIAN STUDENT APPLICATION
Visionary Health Career Training Institute LLC
Please fill out the entire form below.
Certified Phlebotomy Tech Student Application
Program Applying For
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Certified Phlebotomy Technician Training (In-Person)
Preferred Start Date
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Name
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First Name
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Email Address
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Home Address
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Street Address
Street Address Line 2
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Zip Code
Have you ever applied to Visionary Health Career Training Institute?
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Have you ever been a Phlebotomist?
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Are you a citizen of the United States?
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If no, are you authorized to work in the U.S?
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Are you 18 years of age or older?
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Have you ever been convicted of a felony?
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If convicted, please explain
Education
High School Attended
High School Address
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Did you graduate high school?
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Do you have a high school diploma or GED?
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College
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College Attended
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Did you graduate college?
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Other Education
Other Education Program
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Other Education Start Date
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Did you graduate from Other Education?
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Degree/Certificate of Completion Earned
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References
List persons who can speak about your personal or professional work history
Reference #1
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Reference #2
Reference #2
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Address
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Reference #3
Reference #3
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Address
Street Address
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Employment History
List your last 3 jobs
Employer #1
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Address
Street Address
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State / Province
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Supervisor
Job Title
Responsibilities
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Reason for Leaving
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Employer #2
Employer #2
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Supervisor
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Date
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Employer #3
Employer#3
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Address
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Supervisor
Job Title
Responsibilities
Starting Salary
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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?
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Military Service
Are you a U.S. military veteran?
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Branch of Armed Forces
Rank At Discharge
Type Of Discharge
Dates Served
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Payment Options and Authorization
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CERTIFIED PHLEBOTOMY TECHNICIAN TRAINING IN-PERSON CLASS
8-week training consists of IN-PERSON classroom and lab skills. Financing is NOT based on your credit score. See terms in the FINANCING section.
$
1,245.00
Payment Options
Pay in full (non-refundable)
Pay half now (non-refundable). Pay half later (financed via Denefits*)
Credit Card Details: Must be completed by ALL applicants
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
*FINANCING - Must complete if selected "Pay half now" as a payment option.
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.
Check the box to acknowledge:
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Payment will be processed according to the payment method you selected above. The total amount, including the application fee, is your responsibility and must be paid in full immediately. If any balance remains after your initial payment, you must finance it through Denefits. Please ensure that your payment arrangements with Denefits are finalized BEFORE the start of your classes.
Check the box to acknowledge:
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All deposits are NON-REFUNDABLE after 72 hours of application submission.
Check the box to acknowledge:
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A criminal background check MAY be required.
I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS AUTHORIZATION IS TRUE, CORRECT AND COMPLETE.
Signature
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