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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*


INCOME BASED 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

Email Address

Home Phone

Cell Phone

Work Phone

Social Security# required

Present Total Household Income

Number of Dependents

Are you employed at this time? YesNo

Is your spouse employed at this time? YesNoNot Applicable


SHIP INFORMATION:Check if Same

First Name

Last Name

Address 1

Address 2

City

State

Zip Code


Payment As You Go - $265.00 + $35.00 s/h - $40.00 per month for as long or as little needed to complete the program - US residents only!



None of these payment plans fit my needs. I would like to discuss further options.



I PREFER TO PROVIDE PAYMENT INFORMATION VIA PHONE

CHECKCREDIT CARD

Type of Credit Card VisaMastercardDiscover

Debit Card Debit Card with Visa/Mastercard Logo Only!

Credit Card #

Debit Card #

Expiration Date

Signature:_______________________________ (required by person named on credit/debit card)


SUBTOTAL OF ORDER

MINUS ANY DISCOUNT DEDUCTION

GRAND TOTAL

Additional Comments/Shipping Instructions