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Registration
Registration Form
STOP -
APPLICATION
MUST BE APPROVED BEFORE REGISTRATION
Congratulations on being accepted into the Medical Coding Program!
Please fill out the information below to register.
Contact Information
( * denotes required fields)
Preferred Program Date: *
-- Select Training and Date --
Program 1 Schedule: April 3, 2007 – March 15, 2008
Program 2 Schedule: June 5, 2007 – May 13, 2008
Program 3 Schedule: August 7, 2007 – July 12, 2008
Name: (first, middle, last) *
Social Security #: *
Date of Birth: *
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-
(mm-dd-yy)
Email: *
Emergency Contact Name:
Emergency Contact Relationship:
Emergency Contact Preferred Phone:
[Include Area Code]
Emergency Contact Alternate Phone:
[Include Area Code]
Attn: Scott Johnson
Hartnell College Workforce
Room#104
411 Central Ave.
Salinas, CA 93901
