USERNAME:

PASSWORD:

If paying by check or money order, please complete this form and mail payment to:

Pharmacy Technician Enterprises, Inc.,
601 Portion Road
Suite 208
Lake Ronkonkoma, NY 11779

If paying by credit card, please complete the following electronic application. The process is not complete until your credit card has been successfully charged.

Check desired 2011 Sessions

Session I 2012
Session II 2012
Session III 2012
Session IV 2012
Session V 2012
Session VI 2012

First Name:

Last Name:

Street Address:

City:

State Abreviation:

Zip:

Home Tel. No.:

Work Tel. No.:

Cellphone No.:

Email Address:

Date of Birth:

Last 4 digits of Social Security No.:

Name of High School or Secondary School attended:

Year Graduated:

Lab Coat Chest Size (inches):

Are you interested in a Payment Plan:

Yes No