Name And Professional Information

First Name*

Middle Initial

Preferred Name*

Last Name*

Pronouns*
She/Her/HersHe/Him/HisThey/Them/TheirsOtherPrefer not to respond

Date of Birth*
JanFebMarAprMayJunJulAugSepOctNovDec12345678910111213141516171819202122232425262728293031200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Degree*
MDDOPANPDDSDMDOther

State Issuing Medical License*

Medical License Number*

Specialty 1*

Specialty 2

Contact Information

Primary Email*

Military personnel and government employees must list a non-work email address for their primary email.

Work Email

Home Address:

Street*

Street address only, no P.O. boxes.

City*

State*

Zip*

Personal Phone*

Please use the format 555-555-5555 for US phone numbers.

Work Phone

Please use the format 555-555-5555 for US phone numbers.

Military Personnel & Government Employee Applicants Only

Service Branch
—Please choose an option—Air ForceArmyMarinesNavyVACivilian EmployeeOther

Military Rank

Date of end of obligated service
JanFebMarAprMayJunJulAugSepOctNovDec1234567891011121314151617181920212223242526272829303120262027202820292030203120322033203420352036203720382039204020412042204320442045

Pathway & Tuition*

Indicate the pathway you are enrolling in:*
300-hours220-hours

Tuition payment options:*

(300-hours) Standard Course Tuition: $14,000 by credit card, $13,800 by e-check/check$500 late enrollment fee after September 29.(300-hours) Full-time Resident or Fellow rate (self-pay): $12,500 by credit card, $12,300 by e-check/checkResident/Fellow rate only available if applicant is self-paying. Tuition paid by Residency/Fellowship Program is not eligible for discounted rate. $500 late enrollment fee after September 29.

(220-hours) Standard Course Tuition: $10,500 by credit card, $10,350 by e-check/check$500 late enrollment fee after September 23.(220-hours) Full-time Resident or Fellow rate (self-pay): $9,250 by credit card, $9,100 by e-check/checkResident/Fellow rate only available if applicant is self-paying. Tuition paid by Residency/Fellowship Program is not eligible for discounted rate. $500 late enrollment fee after September 29.

Indicate method of payment:*

ACH (e-check)Preferred - HMI Staff will send an e-check payment link within 48 hours of application submission.CheckPayable to Helms Medical Institute. Contact HMI for mailing address.Credit Card - onlinePay online at https://mkt.com/hmiCredit Card - by phoneCall 510-649-8488 between 10am and 3pm Pacific Time3rd Party PaymentSpecify:

In-person training activities will take place at the Tempe Mission Palms Hotel & Conference Center (Tempe, AZ) for Module One, and the Bolger Conference Center in Potomac, Maryland (just outside of Washington D.C.) for Modules Two and Three. You are requested to lodge at the hotel where a group rate has been arranged. A conference day use fee of $89 per day is required of participants who choose to stay elsewhere or room with another course participant.
For additional information about this course, call 510-649-8488 or e-mail mafp@hmieducation.com. Once you have submitted this online application you will receive a confirmation email.