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Mail or FAX to: CAI Medical Transcription
116 Stillwater Road
Barnegat, NJ 08005
1-866-505-8786
FAX# 1-(609)698-6544


*UPS WILL NOT ACCEPT PO BOXES, PLEASE PROVIDE PHYSICAL SHIP ADDRESS*


*If choosing a payment plan, you may make down payment via check/money order, but be sure to provide a debit/credit card in order for us to secure subsequent payment plan payments*


ENROLLMENT APPLICATION

NAME AND BILLING ADDRESS(as on credit card statement if paying by credit card)

First Name:

Last Name:

Address 1:

Address 2:

City:

State:

Zip Code:

Country:

Email Address:

Home Phone:

Work Phone:

Social Security# required for pay plans & NJ Students:


SHIP INFORMATION:Check if Same

First Name:

Last Name:

Address 1:

Address 2:

City:

State:

Zip Code:

Country:


ENROLLMENT APPLICATION

Pay in Full - US Residents - $930.00 + $45.00 s/h ($830.00 Pay in Full Discount)


Pay As You Go - $330.00 + $45.00 s/h - Plus $50.00 per month for as long or as little needed - US residents only!


CHECKCREDIT CARD

Type of Credit Card:VisaMastercardDiscover

Debit Card:Debit Card with Visa/Mastercard Logo Only!

Credit Card #:

Debit Card #:

Expiration Date:

Signature:_______________________________

Referral # (if any):


SUBTOTAL OF ORDER:

MINUS ANY DISCOUNT DEDUCTION:

GRAND TOTAL:

Additional Comments/Shipping Instructions: