NHA Homestudy Continuing Education Registration/Order Form

I am certified as...

Select all that apply!              Expiration date:
Select Clinical Medical Assistant Medical Administrative Assistant Medical Transcriptionist Phlebotomy Technician EKG Technician Pharmacy Technician Billing and Coding Specialist Medical Lab Assistant Patient Care Associate Nurse Technician  
and
Select Clinical Medical Assistant Medical Administrative Assistant Medical Transcriptionist Phlebotomy Technician EKG Technician Pharmacy Technician Billing and Coding Specialist Medical Lab Assistant Patient Care Associate Nurse Technician
and
Select Clinical Medical Assistant Medical Administrative Assistant Medical Transcriptionist Phlebotomy Technician EKG Technician Pharmacy Technician Billing and Coding Specialist Medical Lab Assistant Patient Care Associate Nurse Technician

and I am ordering the following NHA Homestudy Continuing Education Course(s):

Type in which course(s):

(Separate multiple courses by comma,
  i.e. A1, A2, B1, C1, C2)!

(Click to view list of courses!)

Applicant's Name and Demographics

First Name:                                            Middle Initial:                      

Last Name:

Street:

City:

State:                                             ZIP Code:
Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina Tennessee Texas South Dakota Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Washington DC     

Phone Number:

Email Address:

Date of Birth (MM/DD/YYYY):

Social Security Number:

Total Amount Calculations: (Please Include Shipping Fee)

Payment Options

Check appropriate box if paying by Check, Money Order, or Credit Card!

I will be paying by (check one!)
  check       money order         credit card

ATTENTION: If paying by check or money order do not submit this form online!
Print this form and mail it to the NHA along with your payment in the correct amount!

Make checks payable to NHA and send to:
NHA - National Healthcareer Association
134 Evergreen Place, 9th Floor
East Orange, NJ 07018
 

I am paying by Credit Card!
     Click "Send Form" button then call 1-800-499-9092 with your credit card information!
 

Comments:
Please add any comments here!

 By sending this from I grant permission to the NHA to contact me via email or
       mail to confirm receipt of my information. I understand that this purchase
       will appear on my credit card statement under the name NHA, New Jersey.
        All information provided is confidential. Fraud will be prosecuted to the fullest
       extent of the law

Refund Policy: There are no refunds offered on Homestudy Continuing Education packages!
ANY   QUESTIONS   PLEASE   CALL   1-800-499-9092.