Registration/Application Form

You may enroll online(quickest route) by filling out the application form below AND paying with visa/mastercard 

STEP 1: Pay for the course by clicking the enrollment link on the home page

STEP 2: Come back to this page and fill out the application form below and submit it

That's it! After the above steps are completed watch your email for a receipt for the transaction and other important course related information.

 

Please Enter All Required Fields (marked with *), Enter N/A If A Field Does Not Apply. NOTE: This page and the site’s order page are completely SECURE.

 

Name:*
Address: *
City: *
State: *
Zip: *
Phone: *
Cellular Phone: *
Email Address: *
Do you have a G.E.D or equivalent or other degree? (at a minimum a high school diploma or G.E.D is required to be eligible to sit for the certification exam) * yes
no
Date of birth(Must be 18yrs or older) : *
Social Security Number: *
U.S citizen? * yes
no
If NO, Please provide Alien Id#:
If at address above less than 2 years, previous address:
Driver's license #: *
Expiration (Ex. 07/05): *
Have you ever been convicted of a felony?(If you have been convicted of a felony, you may still qualify for this program as long as it was not drug related) * yesyes
nono
Misdemeanor? * yes
no
If you answered yes to misdemeanor, please explain charge:
Have you ever been found guilty of any drug related charges? (If you have been found guilty then you may not qualify for the program) * yes
no
Are you willing to commit 3 hours, one day a week to learning this career for 12 weeks? * yes
no
Where did you hear about us?
Are you currently employed in a health related field? yes
no
Electronic signature (Please type your FULL name to certify that all of the above information is true and correct and that you wish to register for the course and agree to Rx Learning's terms and conditions, privacy policy and agreement.)***
Please make sure you read our terms and conditions. 

 

 

  

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Pharmacy Tech Training

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