Student Application: Visionary Health Career Training Institute LLC

CERTIFIED MEDICAL ASSISTANT STUDENT APPLICATION

Visionary Health Career Training Institute LLC
Please fill out the entire form below.
Medical Assistant Student Application
Program Applying For
Preferred Start Date

MonthDayYear
Next available class offering (listed on website)
Name*

First NameMiddle Name (if applicable) Last Name
Preferred name (nickname):
Email Address*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Social Security Number*
XXX-XX-XXXX (no dashes or spaces)
Upload a copy of your social security card.*

Social Security Card
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Upload a copy of your government issued photo identification.*

Passport, visa, state ID, or state driver's license
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Date of Birth*
MM-DD-YYYY
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Have you previously applied to Visionary Health Career Training Institute?

YesNo
Have you ever been a Medical Assistant?

YesNo
We are Vocational Rehabilitation Service Partners. Were you referred by AL Dept Rehabilitation Services? (If unsure, leave blank)

YesNo
Are you a citizen of the United States?*

YesNo
If no, are you authorized to work in the U.S?*

YesNo
Are you 18 years of age or older?*

YesNo
Have you ever been convicted of a felony?*

YesNo
If convicted, please explain
Education
High School Attended
High School Address
City, State
High School Start Date

MonthDayYear
Date
High School End Date

MonthDayYear
Date
Did you graduate high school?

YesNo
Do you have a high school diploma or GED?

DiplomaGED
College

If you did not attend college, leave this section blank
College Attended
College Address
City, State
College Start Date

MonthDayYear
Date
College End Date

MonthDayYear
Date
Degree type

AssociateBachelorsOther
Did you graduate college?

YesNo
Other Education
Other Education Program
Other Education Address
Other Education Start Date

MonthDayYear
Date
Other Education End Date

MonthDayYear
Date
Did you graduate from Other Education?

YesNo
Degree/Certificate of Completion Earned

YesNo
References

Someone who can speak about your personal or professional history
Reference #1

First NameLast Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Reference #2
Reference #2

First NameLast Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Reference #3
Reference #3

First NameLast Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Employment History

List your last 3 jobs
Employer #1
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor
Name
Job Title
Responsibilities
Starting Salary
Ending Salary
From

MonthDayYear
Date
To

MonthDayYear
Date
Reason for Leaving
May We Contact Supervisor?

YesNo
Employer #2
Employer #2
Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor
Name
Job Title
Responsibilities
Starting Salary
Ending Salary
From

MonthDayYear
Date
To

MonthDayYear
Date
Reason for Leaving
May We Contact Supervisor?

YesNo
Employer #3
Employer #3
Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor
Name
Job Title
Responsibilities
Starting Salary
Ending Salary
From

MonthDayYear
Date
To

MonthDayYear
Date
Reason for Leaving
May We Contact Supervisor?

YesNo
Military Service
Are you a U.S. military veteran?

YesNo
Branch of Armed Forces
Rank At Discharge
Type Of Discharge
Dates Served

MonthDayYear
Start date
Dates Served

MonthDayYear
Discharge date
If other than honorable discharge, please explain
To receive your 10% military discount, please upload proof of service (US military ID, etc.) AND call 251.288.4007 for your promo code.

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Payment Options and Authorization

My Products*

CERTIFIED MEDICAL ASSISTANT TRAINING IN-PERSON CLASS 12-week training consists of IN-PERSON classroom, lab skills, and a 40 hours internship. Must be paid in full (non-refundable) to enroll.

$2,300.00

Enter coupon

Total

$0.00

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:*

Payment will be processed according to the payment method you selected above. The total amount is your responsibility and must be paid in full to enroll.
Check the box to acknowledge:*

All deposits are NON-REFUNDABLE after 72 hours of application submission.
Check the box to acknowledge:*

A criminal background check MAY be required.
I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS AUTHORIZATION IS TRUE, CORRECT AND COMPLETE.
Signature*

Clear
Date*

MonthDayYear
If you encounter any problems while checking out, please call 251.288.4007.
Payment Methods

Choose from one of the PayPal options to make your payment.
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CERTIFIED MEDICAL ASSISTANT STUDENT APPLICATION

Education

College

Other Education

References

Employment History

Military Service

Payment Options and Authorization

Disclaimer and Signature

I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS AUTHORIZATION IS TRUE, CORRECT AND COMPLETE.