Admission Application
I wish to apply for the following program (Circle One):
Phlebotomy Technician Office Administrative Assistant
Medical Assistant Medical Billing & Coding
Medical Office Specialist Patient Care Technician
Student’s Name:
Mailing Address:
Contact Phone:
Email Address:
Education (Diploma/ G.E.D., year of award, school, and other details):
Previous Traning, if any:
Any other information you like to mention for admission decision:
Documents Attached:
Drivers License/ State ID
Social Security Card
Diploma/ G.E.D.
All applicants must submit this application with $25.00 non-refundable fee
________________________ _____________________
Your name(Print) Signature & Date
Email the filled in form to admin@texashealthtech.com