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
Please Select
Certified Medical Assistant Training (In-Person)
Preferred Start Date
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Month
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Day
Year
Next available class offering (listed on website)
Name
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First Name
Middle Name (if applicable)
Last Name
Preferred name (nickname):
Email Address
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example@example.com
Cell Phone Number
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Social Security Number
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XXXXXXXXX
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Social Security Card
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Upload a copy of your government issued photo identification. (passport, visa, state ID, state driver's license)
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Government Issued Photo ID
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Home Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Have you previously applied to Visionary Health Career Training Institute?
Yes
No
Have you ever been a Medical Assistant?
Yes
No
Are you a citizen of the United States?
*
Yes
No
If no, are you authorized to work in the U.S?
*
Yes
No
Are you 18 years of age or older?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
If convicted, please explain
Education
High School Attended
High School Address
City, State
High School Start Date
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Month
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Year
Date
High School End Date
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Year
Date
Did you graduate high school?
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Do you have a high school diploma or GED?
Diploma
GED
College
If you did not attend college, leave this section blank
College Attended
College Address
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College Start Date
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Day
Year
Date
College End Date
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Day
Year
Date
Degree type
Associate
Bachelors
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Did you graduate college?
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No
Other Education
Other Education Program
Other Education Address
Other Education Start Date
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Month
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Day
Year
Date
Other Education End Date
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Month
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Day
Year
Date
Did you graduate from Other Education?
Yes
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Degree/Certificate of Completion Earned
Yes
No
References
Someone who can speak about your personal or professional history
Reference #1
First Name
Last Name
Relationship
Company
Phone Number
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Address
Street Address
Street Address Line 2
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State
Zip Code
Reference #2
Reference #2
First Name
Last Name
Relationship
Company
Phone Number
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Address
Street Address
Street Address Line 2
City
State
Zip Code
Reference #3
Reference #3
First Name
Last Name
Relationship
Company
Phone Number
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Address
Street Address
Street Address Line 2
City
State
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
City
State
Zip Code
Supervisor
Name
Job Title
Responsibilities
Starting Salary
Ending Salary
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Reason for Leaving
May We Contact Supervisor?
Yes
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Employer #2
Employer #2
Name
Phone Number
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Address
Street Address
Street Address Line 2
City
State
Zip Code
Supervisor
Name
Job Title
Responsibilities
Starting Salary
Ending Salary
From
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Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Reason for Leaving
May We Contact Supervisor?
Yes
No
Employer #3
Employer #3
Name
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State
Zip Code
Supervisor
Name
Job Title
Responsibilities
Starting Salary
Ending Salary
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Reason for Leaving
May We Contact Supervisor?
Yes
No
Military Service
Are you a U.S. military veteran?
Yes
No
Branch of Armed Forces
Rank At Discharge
Type Of Discharge
Dates Served
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Month
-
Day
Year
Start date
Dates Served
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Month
-
Day
Year
Discharge date
If other than honorable discharge, please explain
Payment Options and Authorization
Choose your payment option below:
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CERTIFIED MEDICAL ASSISTANT TRAINING IN-PERSON CLASS
12-week training consists of IN-PERSON classroom, lab skills, and a 40 hours internship.
$
2,000.00
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 be completed if selected "Pay half now" as a payment option. SKIP THIS SECTION if you selected "Pay in full" 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:
*
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:
*
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
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Date
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