Please Print Clearly:
FIRST NAME: ___________________ Middle _______________ LAST NAME: _______________________
(Name or Initial)
Mailing Address:
Street or P.O. Box: City: State: Zip
________________________________________ _____________________ _________ ____________
Home Phone: ________________ Work Phone: ________________ Cell Ph: _______________
e-mail address: __________________________________ Web site: http://www. ________________________
Marital Status: Married □ Single □ Date of Birth: _____________________________
Highest education level or degree:_______________ High School Graduation or GED award date: ______________
Employer: ______________________________ Occupation: ___________________________
Are you now or have you ever been under the care of a Psychiatrist ?
No □ Yes □ If yes, please give details of your condition, inclusive dates of treatment, and list any medications prescribed. __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Reason for taking this course: ___________________________________________________________________
Have you ever been convicted of a Felony?
No □ Yes□ If yes, please give details: __________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
I certify that the information on this application is complete and accurate to the best of my knowledge. I understand that misrepresentations on this form may be cause for refusal of admission or immediate suspension from the course.
Each Module is $895.00
I enclose a check or money order for $100.00 as a deposit for Module I and agree that the balance of monies due for each module is to be paid not later than the first day of the module unless prior arrangements have been made.
Signature: __________________________________________ Date: ____________________
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