CAI Medical Transcription Order Form

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

*NOTE: $100.00 DEDUCTION FOR PAY IN FULL ENROLLMENT - Not applicable to Income Based Option

Pay in Full - US Residents - $1530.00 + $35.00 s/h ($1430.00 if paid in full)

Payment Plan 1 - $765.00 x 2 payments - 1st payment $765.00 + $35.00 s/h - 2nd payment auto billed in 30 days - US residents only!

Pay Plan 2 - $450.00 down + $35.00 s/h - 6 payments of $185.00 auto billed monthly - (includes one time $30.00 processing fee) - US residents only!

Career Choice Guide/Free Tape (US residents) - $55.00 + $7.00 s/h

Choosing Medical Transcription As A Home Business (complete guide to MT home business) included in course, but also offered separately (US residents) - $55.00 + $7.00 s/h

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: