New Online Application

Altamont Healthcare
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Online Application

Personal Information

Application Type

First Name

Middle Name

Last Name

Birth Date

Driver’s License/ID No.

Home Phone

Cell Phone

Work Phone

Street

City

State/Province

Zip/Postcode

Ethnicity

Gender

Scrub Size

How did you hear about us?

If other, please specify lead source?

Emergency Contact Person

Cell Phone

SMS

Relationship

Previous Education

High School Name

HS City/State

Year Graduated

Diploma/GED

HS Diploma or Equivalent

Name of College

if applicable

City/State

Currently Attending/Did Not Finish/Graduated

If Graduated, indicate year of graduation

Degree/s Obtained

Transcript Copy

Highest Level of Education

Background Information

Current job title

if employed

Name of Employer

City/State

List major medical conditions/allergic reactions

if any

Name, number and address of primary doctor

List misdemeanors or felonies in the last 10 years

if any

What is the status of these offenses?

Gov-issued ID/DMV ID

Educational Service

Program

Enroll In

Class Schedule

Campus

Terms & Conditions

Due to regulatory policies, you are required to read the school catalog and SPFS document which can be found at the following link: https://www.altamonthealthcare.com/bppe-documents

I hereby agree that I have read and will sign the SPFS document.

I agree

I do not agree

I hereby agree that I have read the institutional catalog

I agree

I do not agree

By submitting this document, I agree to the terms laid out in the school catalog and understand that my $250 registration payment is non-refundable.

I agree.

I do not agree and I will forfeit my ability to enroll.

Payment Information

Items	Amount
Tuition	$0.00
Total	$0.00

Payment Method

Required

First Name (as on card)

Same as applicant first name

Required

Last Name (as on card)

Same as applicant last name

Required

Address (as on card)

Same as applicant address

Required

City (as on card)

Same as applicant city

Required

State/Province (as on card)

Same as applicant state

Required

zip (as on card)

Same as applicant zip

Required

Phone Number

Required

Credit Card Type

Required

Card Holder Name

Required

Card Holder ID / RIF

Required

Credit Card Number

Required

Expiration Date

Required

Security Code

Required

Currency

USD

Account Number

Required

Routing Number

Required

Enter the above code

Required