National Personal Training Institute

*First Name:

*Last Name:

*Email:

*Phone:

*Address Line 1:

Address Line 2:

*City:

*State/Province:

*ZIP/Postal Code:

*Date of Birth:

Social Security Number:

*How did you hear about our program:

*Have you attended an open house or an individual appointment:

Yes No

*Have you been convicted of a felony:

No Yes

*Campus location you will be attending:

Cleveland (Richmond Heights) Columbus

*Class Schedule:

July; Monday-Thursday (9:30am-2:30pm): July 12, 2010-January 6, 2011 October; Monday-Thursday (9:30am-2:30pm): October 11, 2010-April 7, 2011 October; Tuesday (5:30-10:30pm)/Thursday (5:30-10:30pm)/Saturday (10:00am-6:00pm): October 12, 2010-April 11, 2011 October; Tuesday (5:30-10:30pm)/Thursday (5:30-10:30p)*: October 12, 2010-October 6, 2011

*Please note that students enrolled in the one-year option must attend class on the first three Saturdays of the program from 10:00am-6:00pm.

*Payment Option:

Pay In Full Two One-Half Payments Interest-Free Payment Plan Educational loan via Clark Behavioral Health Financing.

*How will you pay the enrollment fee-
(You will not be enrolled until your enrollment fee payment is received and processed):

Check or Money Order. Please make payable to NPTI and send to: 3496 Snouffer Road, Suite 100, Columbus, Ohio 43235. Credit Card. (Please fill out your credit card information below).

Name on Credit Card:

Credit Card Billing Address:

Credit Card Billing Phone Number:

Credit Card Number:

Expiration Date:

Card Identification Number (CID):

Amount to Charge to Card:

Submit Form:

By submitting this form you certify that all the information contained in this enrollment form is true and complete.

Enrollment Form