Pro-Learn Secure Enrollment Form

Course Desired Level 1 (Online) Level 2 Date: Location: Level 3 (Online) Pedorthic Shoe Tech (Online)
Student Name As desired on certificate
Company
Address
City
Zip
State
Email Address
Social Security #
Phone
Fax
Professional Designation CO, MD, CFO, CFts
Related Experience
Education
Race / Ethnic Background (Optional)
Date of Birth (Optional)
Gender (Optional) Male    Female
American Indian (Optional) Yes    Paternal   Maternal   Both    Unknown
(Optional) Hispanic    Nonresident Alien
(Optional) Disabled
Enrollment Fee Level 1 Normally 750, 650 with fitter discount
Enrollment Fee Level 2 Normally 1500, 1400 with fitter discount
Enrollment Fee Level 3 Normally 750, 650 with fitter discount
Enrollment Fee PST Program 395 (SSIA members only)
Credit Card Type Visa    MasterCard                       Sorry, we do not accept American Express
Credit Card Number
Expiration Date
3 Digit Security Code on back
Name on Card
Billing Zip
Authorization I hereby authorize Pro-Learn, LLC to charge this card.
Comments or Questions

These is no cash refund for educational products (Distance Learning) once username and password has been issued. Pro-Learn will offer a credit for the refund amount to be applied to any substitute enrollment.

 

Download printable form here