Phlebotomy Registration Form

Name *

First

Middle

Last

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Date of Birth *

Gender *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Select the type of Identification you are using, take a photo of your ID, and upload it.

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ID Type

File Upload (Accepted extensions: .png, .gif, .jpg)

Click or drag a file to this area to upload.

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Student Email *

Cell Phone

Home Phone

Work Phone

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High School

Graduation Date

BJCs

BGCSEs

Do you have a College/University Degree or Credits?

Select

College/University Degree

Number of College/University Credits

Registration Agreement *

I understand that there is a $100.00 Non-Refundable Registration Fee and submission of this Registration Form only provides ATLAS Medical Labs my required information for the course. However, it does not secure registration for the course until I complete payment of the required Registration Fee.