Strictly Phlebotomy ATL Registration Form

Strictly Phlebotomy ATL Registration Form

Register for your preferred class and upload the required documents.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Which class do you want to attend?

Other
T-shirt Size & Scrub Size
Upload your proof of ID and high school diploma or GED

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Please upload a headshot for your badge.

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Payment Options
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Phlebotomy or EKG Program
Full Payment, if paying in full do not pay application fee

$1,350.00 Quantity



Program Application fee and Deposit

$350.00 Quantity



Cash
For Payments made in person or by Invoice

Free Quantity



NHA Exam
$135.00 Quantity



Total

$0.00
Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info
Should be Empty: