Health Information Technology - Certification Program
Interest Profile

Continuing Ed

Filling out this form does not enroll you in any FDTC program. After submission of the form, you will be added to our Health IT mailing list and we will keep you updated on the Health IT certification program.

Please complete the appropriate information, certify that the information provided is correct and accurate, then submit.

Name:

**Required**

 First:      Last:

Street:

**Required**

City/State/Zip:

**Required**

Daytime Phone Number:

**Required**

( ) - -

Email:

**Required**

Certification you are Interested In:

**Required**





Degree:

**Required**




Degree Level:

**Required**

Experience:

**Required**



Comments: