Please print, fill, and fax this form to:

Fax: 704-319-5517

__________________________________________________
Legal Nurse Consulting Center, Inc.
7810 Ballantyne Commons Parkway
Suite 300
Charlotte, North Carolina 28277
Telephone: (704) 319-5516
Fax this form to: (704) 319-5517

 

2009 HOME BASED LNC PROGRAM APPLICATION

 

Name: ______________________________________ Date: _________________

Address: ___________________________________________________________

City: __________________________________State______ Zip: _____________

E-Mail Address: __________________________ Phone:(h) _________________ (w) _________________

We will never share your name with anyone nor ever send you any unwanted solicitations.
Name, address, email and phone are all necessary for sign up purposes.

Nursing License: _________ License in good standing w/ Bd of Nsg, LPN: Yes | No (please circle or underline)

Nursing Specialty (or Area of Practice): __________________________________

Home Based LNC Program $3,400.00 ($50 shipping/handling not included.)

_____ (please mark here)

_____ 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 by phone. Please contact us at (704) 319-5516 if assistance is needed.

* 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 ______________________________________