(573) 893-2060

Career and Technical Education Application

School Name *
Type of Education? *Secondary Membership - $130; $450 per student enrolled Post-Secondary Membership - $450: $700 per student enrolled. Testing Center - $450; for CTE Instructors to conduct testing for TMU	Health Science - Secondary - $130 Health Science - Post-Secondary - $450 Testing Center - $450
Main Contact First Name *Applicants First name
Main Contact Last Name *Applicants Last Name
Main Contact's Title *What is your job title within this business?
Main Contact Credentials *Credentials (i.e. RN, LPN, etc.)
Address *Address
City *City
State *State
Zip Code *Zip Code
Main Contact Email address *Please provider main contact's email address and not a blanketed email such as info@xyz.com.
Main Contact's Phone Number * Contact Phone Number (NO dashes)
Main Contact's Fax NumberFax Number (NO dashes)
Instructor - Point of Contact Name *First and Last Name
Instructor Phone Number *Please enter Instructor Point of Contact phone number if different from main number above. (NO dashes)
Instructor Cell Number *Instructor Point of Contact Cell Number (NO dashes)
Instructor Title *Job Title (Instructor, Examiner, Charge Nurse, etc.)
Instructor Credentials *Credentials (i.e. RN, LPN, etc.)
Instructor Email *Email address
Billing Contact Information *Enter in the billing contact name, mailing address, phone and email (if different from Main contact or instructor contact above.) Otherwise, just enter the name from above that is the billing contact.
Business CountyIf in Missouri, what county are you in?
Business DescriptionPlease provide a business description no longer than 300 characters in length.	300 of 300 characters remaining
Product Type *Please select all Product Types that apply to your business.	Training - Online Learning Training - Schools
Additional School ContactsPlease enter in Name, Address, Phone, and Email for any additional instructors you would like to also be part of MHCA.