TMIKY - Choice MD - IDTKY Enrollment Agreement

CAMPUS INFORMATION:


Admission Representative:  

 

COURSE INFORMATION:

Program Name:
 

 

STUDENT INFORMATION:

Full Name:

Street Address:

City: State:
Zip Code:  

Phone Number: E-Mail:

Social Security Number:  

Birth Date:

Emergency Contact Name:  

Emergency Contact Phone Number:  

Program Type: Certificate  Delivery Method:
 

Total Clock Hours:
              Total Weeks:  

ADDITIONAL PROGRAM FEES NOT INCLUDED IN TUITION

Access Code & E-Book                                            $
 

CPR, TB, Hep B & Uniform                                      $ cost varies (estimated)
Stethoscope                                                             $ cost varies (see catalog)
National Exam                                                          $ cost varies (paid directly to them)
Online Technology Requirements                            $ cost varies (see catalog)
Dental Teeth Fee (If Applicable)                               $ 60.45  (paid to school)

ACCESS CODE ACKNOWLEDGMENT 

Please Check ONE of the Follwing:

If Access Code is included in Financing please select the amount:
 

 

Leave this empty:

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Signature Certificate
Document name: Enrollment Agreement
lock iconUnique Document ID: f209ddce183a47b579ac8aa38142add744e61ef3
Timestamp Audit
August 19, 2022 2:17 pm GMTEnrollment Agreement Uploaded by Greg Goins - [email protected] IP 99.190.9.234
August 19, 2022 2:18 pm GMTTMIKY Documents - [email protected] added by Greg Goins - [email protected] as a CC'd Recipient Ip: 99.190.9.234
October 3, 2022 12:23 pm GMTTMIKY Documents - [email protected] added by Greg Goins - [email protected] as a CC'd Recipient Ip: 99.190.9.234
October 18, 2022 8:09 pm GMTTMIKY Documents - [email protected] added by Greg Goins - [email protected] as a CC'd Recipient Ip: 99.190.9.234
November 2, 2022 1:52 pm GMTTMIKY Documents - [email protected] added by Greg Goins - [email protected] as a CC'd Recipient Ip: 99.190.9.234
November 2, 2022 1:52 pm GMTTMIKY Documents - [email protected] added by Greg Goins - [email protected] as a CC'd Recipient Ip: 99.190.9.234
November 2, 2022 1:53 pm GMTTMIKY Documents - [email protected] added by Greg Goins - [email protected] as a CC'd Recipient Ip: 99.190.9.234
November 10, 2022 2:55 pm GMTTMIKY Documents - [email protected] added by Greg Goins - [email protected] as a CC'd Recipient Ip: 99.190.9.234
December 14, 2022 5:05 pm GMTTMIKY Documents - [email protected] added by Greg Goins - [email protected] as a CC'd Recipient Ip: 99.190.9.234
January 9, 2023 6:38 pm GMTTMIKY Documents - [email protected] added by Greg Goins - [email protected] as a CC'd Recipient Ip: 99.190.9.234
January 9, 2023 11:20 pm GMTTMIKY Documents - [email protected] added by Greg Goins - [email protected] as a CC'd Recipient Ip: 99.190.9.234
January 10, 2023 1:59 am GMTTMIKY Documents - [email protected] added by Greg Goins - [email protected] as a CC'd Recipient Ip: 99.190.9.234