Free Medical Assistant Registration Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Date / TimeDateTimeName *FirstLastPhone *Email *Currently employed as a Medical Assistant *YesNoCurrent EmployerWhat state is your current employer located in?Enrollment *Agreement & Acknowledgment I understand that Free Medical Assistant Certification Week provides the certification opportunity for eligible candidates at no tuition cost. I acknowledge that an Employer Verification Form will be emailed within 1 business day after registration and must be completed by my current or previous employer to confirm qualifying Medical Assistant duties and experience. I understand that submission of registration does not guarantee approval and that my application will be reviewed after employer verification is received. I also acknowledge that a one-time $89 administrative processing fee is required for application review, employer verification processing, file setup, certification processing, and support services. I understand that if my application is denied, the $89 administrative processing fee will be refunded. By checking this box, I confirm that all information submitted is true and accurate and I agree to receive email communications regarding my application and certification process.Signature * Clear Signature state or in? Comment or MessageAdmin feeAdmin Fee Administrative Fee Agreement I agree to the $89 administrative processing fee required to process my application and understand that the fee will be refunded if my application is denied.Stripe Credit Card *Submit
