Medical Billing Course Online Registration Form

Last Name ________________________________First Name ____________________________MI __________

Business Name______________________________________________________________________________

Address ____________________________________________________________________________________

City _________________________________________________ST __________________Zip________________

Wk Phone ________________________Home Phone ______________________Fax______________________

Email Address_______________________________________________________________________________

[ ] I'm Paying with a check          [ ] I'm paying with a credit card          [ ] I'm paying with a money order

Name on Check____________________________________________________________Check #___________

Charge my   [ ] Visa   [ ] MasterCard   [ ] Discover  [ ] American Express

Card #_______________________________________CARD Security Code___________Exp. Date________________

Cardholder Name_______________________________Signature____________________________________