Phlebotomy Technician Training Application
Please ensure that you have all items necessary to complete this form, including your payment method. Falsification of any part of this form is prohibited. Payment is required at the time of submission, unless alternate payment arrangements have been made. If using the payment plan, you must have enrolled and digitally signed your contact and received your code before you will be allowed to submit your application.
Should you have any issues completing this form, please email admin@pesschoolofnursing.com for assistance.
Name
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First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Birthdate
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-
Month
-
Day
Year
Date
Race or Ethnicity (For background check purposes only.)
*
Social Security Number
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Training Dates
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July 1
August 1
September 1
October 1
November 1
December 1
January 1
How will the class be paid for?
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Please Select
Self Pay in Full
Payment Plan
Sponsorship/Scholarship
I have enrolled in a payment plan and have my code. (Failure to do this will see your application removed from the system, and a potential lifetime ban from all programs for falsification of an application.)
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Yes
No
Payment Plan Code (Must have completed a payment plan enrollment, and received your code from PES before you can enroll using this method.)
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Important Notice:
If you are using the Michigan Reconnect Scholarship, you cannot use it for this program. The short term training program ended in July 2024, and we are unable to accept Reconnect students any longer.
If using a sponsorship or scholarship who is your sponsoring organization?
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Who is your contact person and what is their email address for your scholarship or sponsorship? (We will verify this information before you will be allowed to enroll.
*
If using any state of Michigan scholarship, please include the following with your application: Copy of your drivers license, a copy of your award letter, a copy of your high school diploma. These are REQUIRED and MANDATORY if using a state of MI scholarship. Failure to submit these items will see your application removed from our system.
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Terms and Conditions.
Please read these carefully and sign below:
As a self-pay student, I agree to and understand that my payment is non-refundable. Failure to remit payment will result in my application being removed from the system and not being processed.
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I agree
N/A
You consent to receive communications from us electronically. We will communicate with you by e-mail or phone. You agree that all agreements, notices, disclosures and other communications that we provide to you electronically satisfy any legal requirement that such communications be in writing.
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I agree
I agree that if I have marked that I have a sponsor or scholarship, that this is lined up and I am pre-approved and have permission to sign up for this class. If I do not attend the class, and do not notify PES staff that I am unable to attend, I will be charged in full for the class.
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I agree
Falsification of any section on this application (including false sponsorship information) may lead to my my application not being processed and me being dismissed from the program for documentation falsification, and added to the Do Not Admit list for all future programs.
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I agree
I understand that I must follow the course pacing guidelines in the virtual course. Failure to do so will see me removed from the classroom, I will fail the course, and NO REFUND will be issued.
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I agree
I understand that scrubs are required to be worn for my lab days. PES does not supply scrubs, and I am responsible for that cost on my own.
I agree
Signature Required Agreeing to All Terms and Conditions
My Products
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Phlebotomy Technician Training
Phlebotomy Technician Training Program No refunds
$
2,000.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
ACH Bank Transfer
Afterpay
After submitting the form, you will be redirected to Afterpay to complete the payment.
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