STUDENT INFORMATION: 

Name (Last, First, MI):                    
Social Security No.:                         
Mailing Address(for lessons):            
Shipping Address (if different):             

City:     State:     Zip:
Birthdate(M/D/Y):                 E-mail:  

Tel:        FAX:      

Medical Transcription               Electronic Claims Processing

Please complete for demographic purposes only:

Ethnicity:                                                             Gender:

White African American Hispanic Asian American Indian Other                                                    Male Female

New               Readmit

Enter any related training or work experience in the space provided below:

ONLINE REGISTRATION INFORMATION

ENROLLMENT AGREEMENT

I understand that this Enrollment Agreement is a legally binding instrument when submitted by me and accepted by MT Support Services, Inc. in the form of a written acceptance letter.  I  acknowledge that I have read, understand and accept the following: (a) MT Support Services' Refund Policy; (b) All fees and tuition must be paid in full prior to award of Diploma; (c) Upon satisfactory completion of the program and final examination, and once payment in full is received, I will receive a Diploma; (d) this program is designed to be completed in six months, I understand that I have a total of twelve months to complete the program; and (e) my period of enrollment begins once I receive my first lesson from MT Support Services, Inc.

TUITION RECOVERY FUND

MT Support Services, Inc. participates in the Student Tuition Recovery Fund.  This protects all students and assures you that you will suffer no loss of tuition due to the default on the part of the school.

PAYMENT INFORMATION:

Program Cost:        $1700.00 ($725 program materials, $875.00 tuition, $50.00 registration fee, $25.00 CEU fee, $25 postage)

I am paying in full the amount of $1530.00 (which includes a 10% discount).

I am paying my down payment of $500.00 and agree to make six (6) additional monthly payments of $200.00.

In the event that full payment for monthly billing is not made, I agree to pay all costs of collection, including a 33 1/3% Collection Agency Commission, reasonable attorney's fees, and interest on outstanding portion of bill at the rate of eighteen percent (18%) per annum.

Please charge my order to:

Visa               American Express    Master Card       

Card Number               Exp. Date: 

Cardholder's Name:   

INTERNATIONAL STUDENTS: Tuition payment must be in U.S. funds.   Students in Canada, Mexico and other foreign countries are responsible for any applicable custom duties and/or GST.

MT Support Services maintains and promotes equal employment and education opportunities without regard to ethnicity, color, gender, age, religion, handicap, national origin, or other non-merit factors.  Disclosure of social security number, age, gender and ethnicity is optional.

When you have completed this form, click the "Enroll Me!" button once.

Created by A. Jennings.
Copyright © 1997 MT Support Services, Inc. All rights reserved.
Revised: April 09, 2003.