Advanced Registration Form

Phlebotomy Training

Advanced Registration Form

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Wagner Training Institute

PMB 275

700 E. Redlands Blvd, Ste. U

Redlands, CA 92373

800 845-8353

Fax 909 795-4926

Registration Form

Please see schedule for upcoming classes

(Please print your name the way you want it to appear on your certificate)

Name:____________________________________

Address:__________________________________

City:_______________________Zip____________

Phone:___________________________________

Class Location:_____________________________

Class Date:________________________________

Signature__________________________________

Advanced 20hr. Phlebotomy Tuition $250.00

Cashiers Check #________________

Money Order#___________________

Check #________________________

Deposit $_______________________

Balence $_______________________

Date:___________________Sex(M/F)

Advanced Registration Form

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