Edubilling Erudite Institute

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First Name

Last Name

Email Address

Phone Number

Personal Information

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Basic Information

First Name

Last Name

Date of Birth

Gender

Identity Information

PAN Number

Format: ABCDE1234F

Aadhaar Number

12-digit Aadhaar number

Contact Information

Complete Address

City

State

Phone Number

Email Address

Educational Background:

Highest Level of Education Completed

Previous Training or Experience in Medical Billing

Any Certifications or Licenses Related to Healthcare or Billing

Employment Information:

Current Employment Status

Name of the Employer/Organization

Job Title/Position

Emergency Contact Information:

Name of Emergency Contact

Relationship to Student

Contact Phone Number

Accessibility and Accommodation Needs:

Accessibility and Accommodation Needs

Security Information:

Password

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Consent and Agreement:

I consent to Terms and Conditions of Enrollment

I agree to Privacy Policy and Use of Personal Information

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