Truth in Lending Disclosure

Total Price Down Payment Amount Financed Monthly Installments Total of Payments

(The total price of your purchase or (The amount of credit (The amount you will have paid when

credit including your down payment) to you on our behalf) you have made all scheduled payments)

$4,500.00 $1,500.00 $3,000.00 20 @ $150.00 $3,000.00

$4,500.00 $1,000.00 $3,500.00 20 @ $175.00 $3,500.00

$4,500.00 $500.00 $4,000.00 20 @ $200.00 $4,000.00

Instructions
Enrolling in Med-School of Medical Transcription is easy. Simply fill out the personal data requested below, choose the payment plan and method of payment you prefer. As soon as we receive this Agreement and your down payment, or full payment, we will rush the first shipment of your program to you. If you require any further information, please call 928-453-1885.
Information About Yourself
First Name:*
Last Name:*
Address Line 1:*
Address Line 2:		Apt. or Suite No.
City:*
State:*
Zip Code:*
Home Phone:*
Date of Birth:*
Social Security Number*
E-Mail:*
Educational Experience
Do You Have a High School Diploma/GED?*

Please fax your diploma/GED to 888-806-9553 or email to studentservices@medlineschool.com
Tuition Payment Plans
Full Payment Options	I choose to pay the total tuition price of $4,500 MyCAA (Military Spouse Funding) Department of Rehabilitative Services (DARS) Other (Contact Office)

Med-Line Payment Plan (Zero Interest)	$500.00 down, with monthly payments of $200.00 x 20 months $1,000.00 down, with monthly payments of $175.00 x 20 months $1,500.00 down, with monthly payments of $150.00 x 20 months
Auto-payment Agreement (Optional)
Enroll in Automatic Monthly Withdrawals (Using Credit/Debit card below)
Read the Truth in Lending Disclosure
Enrollment: Method of Payment
Charge the credit card I have listed for*
If paying by check/money order, mail to Med-Line School of Medical Transcription, PO Box 2757, Lake Havasu City, Arizona 86405

Card Brand:
Card Number:		No dashes or spaces please
Expiration Month:		From your card
Expiration Year:		From your card
Signature
Your signature below indicates that you have read, understood and accepted the terms in this agreement, as well as the course catalogue dated 01/01/2010. You are not bound by this Agreement until it is accepted by a representative of Med-Line School of Medical Transcription. If you are under the age of 18, please contact the office. Approved and regulated by the Association for Healthcare Documentation Integrity (AHDI). Conditionally licensed by the Arizona State Board for Private Post-Secondary Education.

I have read the Tuition Protection Agreement*
Signature (First and Last Name):*
Tuition Protection Agreement
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Truth in Lending Disclosure

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