CEHRS and CEHRIS Certification Course Enrollment

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First Name*

Last Name*

Address*

Address 2

Town or City*

    State      Zip

Country*

Primary Phone Number*

Secondary Phone Number

Email*

Level of Education*

Select Level of Education High School Diploma or GED Associate Degree Bachelors Degree Masters Degree Doctorate

Current Occupation

Work Experience

  Select Work Experience Less than 2 2 - 5 Years 5 - 10 Years 10 - 15 Years More than 15 Years

Next start date*........

Course Instruction Preference*

  Course Preference Online Instruction ($1,750.00) In-Class in Atlanta - Tuition $3,150.00 (Including Certification) Challenge CEHRIS Certification ($250.00) Challenge CEHRIS and CEHRS Certifications ($500.00)

What industry you are in?

  Industry Pharmaceutical Medical / Healthcare IT Other

How will you be funding your CEHRS certification

  How will you pay for the course? Georgia WIA (Dept of Labour) Funding Full tuition paid before the course starts Full payment - request payment plan or financing Request PHICON Partial Scholarship (50%) Tuition Employer tuition reimbursment

Base on your answer to the previous question, are you requesting a PARTIAL PHICON scholarship?

  Request Scholarship Yes No

Referral Information (How did you hear about this program)?

  Select Referal Google Ad Facebook Main Website Other

If "Other", please list here:

I have read and agree with the Enrollment and & Refund Policy

Yes          No