Admission Application

I wish to apply for the following program (Circle One):

Phlebotomy Technician                   Office Administrative Assistant

Medical Assistant                              Medical Billing & Coding

Medical Office Specialist                  Patient Care Technician

 

Student’s Name:

Mailing Address:

 

Contact Phone:

Email Address:

Education (Diploma/ G.E.D., year of award, school, and other details):

 

 

Previous Traning, if any:

 

 

Any other information you like to mention for admission decision:

 

Documents Attached:

Drivers License/ State ID

Social Security Card

Diploma/ G.E.D.

 

All applicants must submit this application with $25.00 non-refundable fee

 

________________________                                                                        _____________________

Your name(Print)                                                                                                  Signature & Date

 

Email the filled in form to admin@texashealthtech.com