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GENERAL REGISTRATION FORM

Please use this Registration Form to register for all classroom based instruction (EXCLUDING ASTEP).

Your deposit (20%) or full tuition can be paid via credit card directly on the registration form.

If paying by check, please send your check to:

Priority Health Education
PO Box 3267
Chester, Virginia 23831 USA

If paying by Pay Pal please select the Pay Pal Logo below or under the Registration Tab.


REGISTRATION FORM

Please complete this form in its entirety and then submit to Priority Health Education. By submitting the form you agree to all the terms for class participation including attendance and completion requirements.
First Name: *
Middle Name / Initial:
Last Name: *
Address Street 1: *
Address Street 2:
City: *
State: *
Zip: * (5 digits)
Country:
Primary Phone: * HomeCellWork
Secondary Phone: HomeCellWork
 Email: * PersonalWork
Email: PersonalWork
Employer / Facility:
Work Address 1:
Work Address 2:
Work City:
Work State:
Work Zip:
Work Country:
Program: Board ReviewScoring WorkshopPAP 
  Emerging Technology  ASV
Class Location: RichmondFort LauderdaleSlidellStarkville
Other Class Location:
Start Date:
Amount Paid: Deposit (20%)TuitionOther
Payment Method: Master CardVisaDiscoverAmexCheck
  Pay Pal (Select The Pay Pal Logo on the Registration Page)
Credit Card Number:
CVV Code (3-digit code or 4-digit Amex code):
Card Expiration Date:
  Registration is only secured by a minimum deposit of 20% tuition or by payment in full via check or credit card. Priority Health Education reserves the right to terminate the enrollment if tuition balance is not paid in full 15 business days before scheduled course date unless other arrangements have been made. Cancellations made within 30 days of course start date may result in the loss of the 20% deposit. Substitutions of scheduled individuals are allowed up to 5 days before scheduled start date. PLEASE WAIT UNTIL YOU HAVE RECEIVED WRITTEN CONFIRMATION OF YOUR REGISTRATION BEFORE FINALIZING TRAVEL PLANS.:
  By submitting this registration I authorize Priority Health Education to process my payment and register me for the class.

If the name or address of the credit card owner is different from the registration name or address please provide the credit card owners name and address in the comments section BELOW
Promotion Code (If Applicable):
Comments:

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