TEST Enrollment Document


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:  

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: TEST Enrollment Document
lock iconUnique Document ID: 7368336b7aa72aaf0b8da66d100d04b5943c44f4
Timestamp Audit
September 20, 2022 4:10 pm GMTTEST Enrollment Document Uploaded by Greg Goins - [email protected] IP 99.190.9.234