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Apartment #         

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Home Number  *

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 Email Address   *

Alternative E-mail address

What is the Best Time of Day to Contact You?     Mornings    Afternoon

Why are you interested in the medical field?

Which Medical Training Programs Are You Interested in? (Click All That May Apply)

Medical Assistant

Psychiatric Assistant  (Dallas Campus Only)

  Medical Office Assistant

Patient Care Technician

How soon are you planning to start your training?

I'm Ready to Start Now!       Next month           Just Started Planning Not Sure

What is your current education level?

Did not complete High School

Need GED Tutoring Information? No problem PCI offers free GED classes

High School Graduate Please Enter Year of Graduation 

Some College

College Graduate Please Enter Year of Graduation         

HOW DID YOU HEAR ABOUT PCI HEALTH TRAINING CENTER?

Television News Paper Radio Yellow Pages Student Referral Web Site Search Engine Letter InThe Mail Other Referral High School DART BUS AD

ADDITIONAL COMMENTS OR QUESTIONS

Have you ever enrolled or attended PCI? NO  YES