Strictly Phlebotomy ATL Registration Form

Full Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address

example@example.com

Which class do you want to attend?

Other

Scrub Size Top & Bottom

Upload your proof of ID and high school diploma or GED

Please upload a headshot for your badge.

Phlebotomy or EKG Program Application Fee

Program Application Fee

$100.00 Quantity

Program Deposit

Deposit for program due before the start of class

$250.00 Quantity

Phlebotomy or EKG Program

Full Payment, if paying in full do not pay application fee

$1,350.00 Quantity

BLS MS

$50.00 Quantity

Weekly Payment for PBT or EKG Program

$250.00 Quantity

Biweekly Payment for PBT or EKG Program

$500.00 Quantity

Program Application fee and deposit

$350.00 Quantity

MISC.

$650.00 Quantity

Cash

Free Quantity

Total

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info