Health Career Training Associates, LLC
603-622-8400
           New England School of Practical Nursing

IV THERAPY COURSE
REGISTRATION FORM

NAME:_________________________________________________________________
ADDRESS:_____________________________________________________________
______________________________________________________________________
CITY                                STATE                        ZIP CODE

HOME PHONE(      )___________________________
ALT. PHONE(      )_____________________________   
SOCIAL SECURITY#:______________________________
LPN LICENSE #______________________________  
STATE OF LICENSURE__________________________
LPN LICENSE #______________________________   
STATE OF LICENSURE_________________________
* Please attach a copy of your current LPN license
NAME OF TRAINING
FACILITY:______________________________________________________________
_____________________________________________________________________
CITY                                STATE                        ZIP CODE
I AM ACTIVE IN PRACTICE:___________YES__________NO
NAME OF CURRENT
EMPLOYER:________________________________________________________
ADDRESS:_____________________________________________________________
___________________________________________________________________
CiTY                                 STATE                                ZIP CODE


I AM REGISTERING FOR THE  AM_____PM_____ IV THERAPY COURSE   START DATE
___________
ALL SUPPORTING DOCUMENTATION AND PAYMENT IS INCLUDED Yes______ No_____

Mail to:         Health Career Training Associate
                 60 Rogers Street    Manchester, NH 03103

Call for additional information:   622-8400
_________________________________________________________________________

APPLICANT SIGNATURE                                        DATE
Do Not Write below this line
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OFFICE USE ONLY:   ROUTING
Posted  _______ Amt. received  $_________ Paid   Check #_______  Credit Card________  
Agency Auth. ______
Confirmation/invoice/ Course info sent    Date _____________