CLNC® Certification Exam Application

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Complete the payment plan application for the CLNC^® Certification Program by filling out and submitting the form below. It is your responsibility to ensure that this application is properly completed and submitted with the correct down payment to LegalNurse.com (call 713.942.2200 if you have questions).

Select Your CLNC Certification Program:*

VIP Pro - Minimum $1000 Down

VIP - Minimum $500 Down

Executive - Minimum $350 Down

Basic - Minimum $250 Down

The installment plan requires a minimum deposit, and the amount depends on the system. The interest rate will be based upon your deposit, please refer to chart here.

VIP PRO: $1,000 deposit and the balance is financed over a 48-month term.
VIP: $500 deposit and the balance is financed over a 36-month term.
Executive: $350 deposit and the balance is financed over a 24-month term.
Basic: $250 deposit and the balance is financed over a 18-month term.

Down Payment*

Credit Card Information for Down Payment*

Credit Card Number*

CVC*

Expiration Date*

Select Your Payment Date:*

1st

15th

Applicant:

Please fill in all fields (all fields are mandatory):

NOTE: Please enter your name as it appears on your photo ID. The mailing address must match the address on your photo ID.

Social Security Number*

First Name*

Last Name*

Address*

City*

State*

Zip*

Home Phone*

Work Phone

Cell Phone

Email Address*

DOB*

Annual Household Income*

Under $50,000

$50,000-$75,000

$75,000-$100,000

$100,000-$150,000

$150,000-$200,000

Over $200,000

Validation of Application*

I certify the information provided herein is true and complete. I understand my SSN is for identification purposes only and my credit will not be checked. Upon approval, I agree to be bound by the agreement for which this application is provided.

Applicant Signature (type full name)*

Date*

CLNC Certification Program Payment Plan Application