2010 APPLICATION

LEGAL NURSE CONSULTANT CERTIFICATION PROGRAM

Name: ______________________ Date: _

Address: ___________________________________________________________

City: ______________________________State___________ Zip: _____________

E-Mail Address: ________ Phone: _

Necessary for examination purposes only. We will never share your name, address, phone, or email address with anyone nor ever send you any unwanted solicitations.

Nursing License: _________ License in good standing w/Board of Nursing?: Yes No

Nursing Specialty (or Area of Practice): __________________________________

2 Day Accelerated LNC Certification Program: ___ $795

VIP Basic Program (Coupon Applied ) ___$2400

VIP Gold Program (Coupon Applied) ___$3400

VIP Platinum Program (Coupon Applied) ___ $5400

_____City of Seminar_______________________ Date__________________

_____HOMEBASED

CANCELLATION POLICY: Full refund (minus $100 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.

Exception: All Home Based Programs requires a minimum $650 tuition payment plus shipping and handling prior to program. The LNC Center will allow all students FULL credit toward another seminar, if student cancels one day before class begins. Home based students may also transfer to class training from Home Based, with small transfer fee.

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

Signature__________________________________________________________________________

Payment enclosed ____________ ( REMAINING BALANCE TO BE PAID BEFORE LNC PROGRAM COMMENCES).

All applications and deposit checks must be mailed to: Legal Nurse Consulting Center, (address above) or credit card payment is available on line from our website at www.lnccenter.com.

Please telephone us 1 704 319-5516 if assistance is needed.