Complete and submit this on-line enrollment form to enroll. Please note that you will not be officially enrolled until your enrollment form and $25.00 enrollment fee payment have been received and processed.

Personal Information:

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Date of Birth *

Social Security Number *

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

Yes

No

How did you hear about us? *

Program

Please Select Your Program *

Hybrid Personal Training Option #1 (Includes the personal training certification tuition refund program)

Hybrid Personal Training Option #2 (Include CPT exam prep)

Class Schedule-Hybrid Personal Training

Please Select Your Class Schedule

February 4-April 23, 2020

April 28-July 16, 2020

July 21-October 8, 2020

October 6-December 22, 2020

Classes are offered each Tuesday and Thursday from 10:00am-2:00pm (Day Class) and 5:30-9:30pm (Night Class).

Night Class

Day Class

Education

Highest level of education achieved? *

Name of school from which you received your GED or high school diploma *

Location (city and state) of the school from which you received your GED or high school diploma *

Day, month and year you received your GED or high school diploma *

Payment Information

Payment Options *

How will you pay the $25.00 enrollment fee? *

Check or money order. Please make payable to NPTI and send to: 10516 Sawmill Road, Suite C, Powell, Ohio 43065

Credit card. Please fill out your credit card information below. (A 2% surcharge will be added for charges over $200.00)

Enrollment Fee $25.00

Cardholder's Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Credit Card Type *

Credit Card Number *

Security Code *

Expiration Date (mm/yy) *

By submitting this form I attest that all the information contained in this enrollment form is true and complete and that I have received a high school diploma or equivalent as identified above.