Register for On-Line: Medical Information Management and Office Practice

Please complete the following form to complete your registration. Name and address information must match the information associated with your credit card.

You must complete all fields on this form. All data is required.

Name:
Name of Student (if different from above):
Student Date of Birth:Month: Day: Year:
Address:
City:
State:
Zip:
  
Phone:
E-Mail: