How to Enroll

Application for Mold Training and Certification

For Study Mold at Home, fill out this application and mail it to the address below with payment, or if paying by credit card over the phone, you can fax this application to (435) 656-8939. If paying by check please make checks payable to:

Millennial Health Services
c/o Paul Brennan
150 E. 300 N.
Ivins, Utah 84738
U.S.A.

This application is also available in Adobe pdf format.

Full name: ____________________________________

Mailing Address: ____________________________________

Daytime Phone (______)_________________

Evening Phone (______)_________________

Email Address:____________________________________

Fax (______)_________________

If you have completed any post-high school college, trade, or technical education programs of any kind, please provide the details including school name, location, year of graduation or completion of course, subjects studied, and any other helpful information. Attach extra sheets of paper if needed.

Please describe in detail all of your business/work/career experiences that you believe would be helpful to your successful career as a Certified Mold Testing Specialist, or Certified Mold Remediation Specialist. Please include details such as skills learned, employer names and addresses, and from when to when. Attach extra sheets of paper if needed.

Please provide the names, nature of relationship [how you know each person], company [if relevant], complete mailing address, and current phone number of at least three persons who personally know your work abilities and/or general character. Your most ideal references would be your business/professional clients or coworkers. Please do NOT submit references who are your relatives or employees. Attach extra sheets of paper if needed.

If accepted by Millennial Health Services, I and the organization that I represent will always follow the Code of Ethics of MHS.

I enclose $995.00 as payment for tuition and annual membership dues. Please send my home study packet for mold training and certification.

I certify that the above information is totally true and complete. I authorize my references to provide complete information about myself to Millennial Health Services.

____________________________________________
My signature

_____________________
Date

Adobe PDF Application

Click here to download this application as an Adobe pdf file. (21 KB)

You will need Adobe Acrobat Reader software to read this document. If you do not have this software, you may obtain a free copy by following this link.