2009APPLICATION
LNC CENTER CERTIFICATE PROGRAM

Name: ______________________________________ Date: _________________

Address: ___________________________________________________________

City: __________________________________State______ Zip: _____________

E-Mail Address: __________________________ Phone: ___________________
We will never share your name with anyone nor ever send you any unwanted solicitations.
Name, address, email and phone Necessary for examination purposes.

Nursing License: _________ License in good standing w/ Bd of Nsg, LPN: Yes 0 No 0

Nursing Specialty (or Area of Practice): __________________________________

Legal Nurse Consulting Certification Program: $3400____ . Group Rate: $3000____. Silver Program (1 year Mentorship):
$4200____. Gold Program: $5400____. Ask about early sign-up rates for Gold and Silver Programs!

Basic Program:

• $3,400.00 (Single Rate: 30-45 day Program)
• $4,200.00 (Silver: 1-year of Mentorship Program)
• $5,400.00 (Gold: Lifetime Mentorship Program)
• $3,000.00 (Group Rate - 3 or More Students)

*Tuition includes all materials, books for complete 40-Day program.

2009 Classroom Instruction commences:

• ____ February 3-5: Ft. Lauderdale, FL
• ____ February 24-26 : Charlotte, NC
• ____ March 10-12: Los Angeles, CA
• ____ March 31-April 2 : Baltimore, MD
• ____ April 7-9 : Manhattan , NY
• ____ April 14-16 : Boston, MA

____ All applications/ deposit checks must be mailed to: Legal Nurse Consulting Center, 7810 Ballantyne Commons Parkway, Suite 300, Charlotte, North Carolina 28277. Credit card payment is now available on-line from our website at www.lnccenter.com, or by phone. Please contact us at (704) 319-5516 if assistance is needed.

Enclosed ____________ (50% DEPOSIT WITH REMAINING BALANCE TO BE PAID BEFORE LNC PROGRAM COMMENCES).

CANCELLATION POLICY FOR SEMINARS:

Full refund (minus $50 Registration Fee) with 7 or more days notice. IF CANCELLATION OCCURS 6 DAYS OR LESS, YOU MAY RECEIVE FULL TUITION CREDIT TOWARDS A FUTURE PROGRAM OFFERED, NO MONIES WILL BE REFUNDED.

* Live Web Conferencing Program or Home Certification Program requires 100% tuition payment plus shipping and handling prior to program. There is no refund once course materials are shipped to your residence.

____ I have read the above and agree to the terms. To the best of my knowledge all answers above are correct and true.

Signature __________________________________________________________________________