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Personal Fitness Training Program

Online Application for Admission


First Name:
Last Name:
Address Line 1:
Address Line 2:
City:
State:
Zip:
Home Phone:
Work Phone:
Birth Date - mm/dd/yy
Social Security #:
Citizenship:

PROGRAM

Select the program you are applying for from the list below.

EMPLOYMENT:

List current or most recent employment.


Employer
Address
City/State:
Phone
Job Description:
Dates Employed:

HEALTH RECORD:

Have you had any contagious diseases in the past 2 years? No Yes
If yes, please explain.
Do you have any health related issues the school should be aware of? No Yes
If yes, please explain.

OTHER:

Have you ever been convicted of a felony? No Yes
If yes, please explain.

How did you hear about us?
Other (please specify):

CERTIFICATION:

Type your full name in the space below to indicate that you believe the information provided above is true and complete.


Your Full Name:

PAYMENT:

Provide your charge card information for the $75.00 registration fee. The $75.00 registration fee is refundable prior to the first day of class.

Email Address:

Name on Card:

Credit Card Data:

Credit Card #:

If you want a copy of this page for your records, print it now before you submit the page.

Click on the Submit button just once. Depending on Internet traffic and server load it may take up to one minute for the order to be processed. However, if nothing seems to be happening, feel free to click again. You will not be billed twice.

The National Personal Training Institute
of Southern California, INC.
5319 University Drive #305
Irvine , California, CA 92612

Toll Free: 800-460-0933
Fax: 949-733-8108
Email: npti@cox.net

National Personal Training Institute	Toll Free: 1- 800-460-0933
2651 Irvine Ave Suite 118 Costa Mesa, CA 92627	Fax: 1-949-631-6039 Email: npti@cox.net