Full Name: __________________________________________

(First name for badge)______________

Organization/Referred by:______________________________________

Preferred Mailing Address:______________________________________

City: ____________________State: _____ Zip/Postal Code:__________

 Telephone: (______)___________________________

Email:______________________________________

Emergency Contact: ______________________ Relationship: ____________

COURSE FEES

Registration Fees (All fees listed in U.S. Funds.) Includes Textbooks, Material Handouts & Lunch

Please check appropriate registration fee:    

                                                             

 Tuition                                                $2500.00

 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:________