PRE-REGISTRATION FORM

Please fill up the form and click submit
* are required fields

Last name *

First Name *

Middle Name

Address *

Zip Code *

Area Code

Telephone

Mobile

Email *

Birth Date *

Gender

Civil Status

Citizenship

Desired Course *

Interested in *

Highest level of education

School

School Address

Degree/Course

Year Graduated

If under Grad Level

Licensure/Government Exams

Year Taken

Rating

Position

Company

Company Address

How did you find out about this program?

Why do you want to pursue a career in Medical Coding and Billing?

Computer Literacy rate [5 as highest]