MedDoc Training Enrollment Application

MedDoc Training Enrollment Application
Full Name
Date of Birth

MonthDayYear
Date
Address
CityStateZip
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Required Documentation: Submit your picture ID below.
Take Photo
Do you have one of the following:

High school Diploma

GED

If neither you can email us a written statement explaining why you chose MedDoc Training. (meddoctraining1@gmail.com)

If you have one of the follwoing upload the picture below.
Take Photo
Please select the program and tuition rate you are enrolling under:

Standard Training Package (6 Weeks) - $700 Standard Training Package (6 Weeks, Discounted) - $350

Advanced Training Package (8 Weeks) - $1200 Advanced Training Package (8 Weeks, Discounted) - $600
Check only one option above
Name on Card Used for Payment
If the cardholder is not the student, check below and attach required documentation: I have permission to use this card, and I will submit a copy of the cardholder's valid ID.

Submit the cardholder's ID below.
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Terms & Conditions (Initial Each Statement)
Student Responsibility - It is your responsibility to complete all coursework, assignments, and seminars within the allotted time.
Student Responsibility - It is your responsibility to complete all coursework, assignments, and seminars within the allotted time.
requirements.
Final Acknowledgment & Signature

I, the undersigned, certify that the information provided is true and correct to the best of my knowledge. I have read, understood, and agree to all Terms & Conditions above, and I understand the documentation requirements for enrollment.
Student Signature
Date

MonthDayYear
Date
Should be Empty: