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HOMEMAKER HOME HEALTH AIDE (HHHA) ENROLLMENT FORM
ALL INFORMATION MUST BE ACCURATE. THEY ARE SENT TO THE OFFICE OF CONSUMER AFFAIRS
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Email
*
Your email
LAST NAME
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Your answer
FIRST NAME
*
Your answer
STREET ADDRESS
*
Your answer
STATE
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Your answer
ZIP CODE
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Your answer
COUNTY (WHAT COUNTY DO YOU LIVE IN?)
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Your answer
SSN (DO NOT MAKE ANY MISTAKE PLS)
*
Your answer
TELEPHONE NUMBER
*
Your answer
EMAIL ADDRESS (GMAIL PREFERRED)
*
Your answer
ARE YOU READY TO ENROLL IN CHHA TRAINING (CHOOSE YES IF YOU ARE READY TO ENROLL)
Yes
No
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TOTAL HOURS OF TRAINING. (TYPE 76 HOURS)
*
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PAYMENT OPTIONS
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FULL PAYMENT $510
TWO INSTALLMENTS $255 AND $255
Row 1
FULL PAYMENT $510
TWO INSTALLMENTS $255 AND $255
Row 1
FOR 2 INSTALLMENTS, SPECIFY THE 2 DATES
*
Choose
Option 1
Option 2
PAYMENT OPTIONS
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CASHAPP:
cash.app/$ABCHST
ZELLE: 917-957-4237
PayPal:
paypal.me/goabovegobeyond
CONSENT TO POST YOUR SKILLS TRAINING PHOTOS/VIDEOS ON SOCIAL MEDIA
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YES
NO
STUDENT SIGNATURE AND DATE
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Your answer
INSTRUCTORS SIGNATURE AND DATE
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