Book Your Course ( 3 Day Weekend)

ADVANCE 3 DAY WEEKEND PHLEBOTOMY COURSE

Please be advise this course is for those whom already have a medical history background and can show proof. Example: med-school, nurse, medial assistant, certified nursing assistant, etc.

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Can you present a valid ID?

Yes

No

Can you provide a high-school transcript, GED, or diploma?

Yes

No

Can you provide proof of medical background?

Yes

No

Do you have a criminal record, felony?

Yes ( if yes please contact us ASAP)

No

Course Date

Deposit

$250

Signature

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I understand and have filled out this entire form to the best of my ability. I am aware that this is a deposit only form and I agree to pay the $250 non refundable deposit with the remaining balance of $750 is due the first day of class.