subject_line
Secure Order Form
Choose the program below to enroll now!
Program Information
Please enroll me in the following program:
*
Pharmacy Technician
Medical Billing
Medical Coding
Administrative Medical Assistant
Administrative Medical Assistant & Pharmacy Tech
Administrative Medical Assistant & Medical Billing
Administrative Medical Assistant & Medical Coding
Medical Billing & Coding
Pharmacy Tech & Medical Billing
Pharmacy Tech & Medical Coding
I choose the following payment plan:
*
Full Payment $2,000 --(All Additional Fees Waived This Month Only!)
$250.00 down + 24 monthly payments of $72.92
I choose the following payment plan:
*
Full Payment $4000.00 (All Additional Fees Waived This Month Only!)
$500.00 down + 24 monthly payments of $145.83
Personal Information
First Name
*
Last Name
*
Street Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Phone Number
*
Email Address
*
Payment Information
Name on Card
*
Credit Card Type
*
Visa
MasterCard
American Express
Discover
Credit Card Number
*
Exp. Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Exp. Year
*
2012
2013
2014
2015
2016
2017
2018
2019
2020
CVV/Security Code
Other Information
How did you hear about us?
*
Bookoo
Craigslist
Email Ad
Employee Referral
Family/Friend
Internet
MYCAA
Other
Postcard
Word of mouth
Yard Sales
If I selected a monthly payment plan, I understand that the total down payment will be processed on my credit card today.
*
Yes
No
Special Instructions
Powered by