Full Name: __________________________________________
(First name for badge)______________
Preferred Mailing Address:______________________________________
City: ____________________State: _____ Zip/Postal Code:__________
Emergency Contact: ______________________ Relationship: ____________
Registration Fees (All fees listed in U.S. Funds.) Includes Textbooks, Material Handouts & Lunch
Please check appropriate registration fee:
Medical Employee Tuition $2400.00
Count me for lunch: YES/NO Vegetarian meals required:_____
Allergic to the following: _____________________________________
Please list any ADA Special Needs :______________________________
Cancellations/Changes and Refunds: Tuition fees for student cancellation are non-refundable. No make-up classes due to absences/tardiness. California Academy of Medical Billing reserves the right to terminate student enrollment at any time due to inappropriate conduct in class.
PAYMENT METHOD Check or Money Order must be in U.S. funds payable to: California Academy of Medical Billing. There will be a $25.00 fee charged on checks returned by the bank due to insufficient funds. Registration confirmation/receipt and further information will be mailed/emailed.
Please check appropriate box:
___ Check ___ Money Order ___ VISA___ MC
Expiration Date: _________
Card #: _________________________________________________ CVC___________
Print Cardholder Name: ______________________________________
Cardholder Signature:_____________________ Date:_______________
Zip Code: ______________________
Please mail or email completed registration form with payment to:
California Academy of Medical Billing
Attn: Joseph R. Martinez 1327 Kansas Circle Concord, CA 94521 925-889-9688
Do not email credit card information because security cannot be guaranteed.
Please fax or telephone credit card information.
I acknowledge the requirements for the course and will abide by the rules of California Academy of Medical Billing.
Registrant Signature: ___________________Date:________