Columbia Review - Home Study Enrollment Form

* 1) Complete lines 1–17 below in full, 2) Print & sign both pages, & 3) Fax or mail one completed form to: Columbia Review Premed eTutors Program, 811 Oregon Avenue, San Mateo, CA, 94402-3307, USA Enrollment Fax: 1-650-348-MCAT (-6228); Phone: 1-650-343-0309 or 1-800-300-PREP Columbia Review is an independent intensive educational program run by medical professionals for premedical students; the program is not run by or affiliated with an undergraduate university or medical school. Our e-Tutorials have been carefully designed by Columbia Review's M.D. and Ph.D. experts to teach and review important concepts and skills commonly needed by premedical students for course, MCAT and medical school admissions success. Since student motivation, study habits, skills and aptitudes differ, Columbia Review cannot make a guarantee or warranty as to student skill development, future test results or medical school application outcome. All e-Tutor suggestions, comments, feedback, and critique are those of your expert e-Tutor and do not necessarily reflect those of all similar experts, other e-Tutors, or the Directors of Columbia Review. Students should always seek multiple sources of expert input and assistance when studying for a course, preparing for the MCAT or when applying to medical school. All e-Tutorial curriculum, content and all related materials (electronic and printed) provided to you are for your personal premed prep use only and CANNOT be shared, given, sold, or shown to ANY other person at ANY time. Course e-Tutor communications can not be duplicated or forwarded to any other person via electronic or any other means. All curriculum, content and course materials are owned and copyrighted by Stephen D. Bresnick, M.D., Director of Columbia Review, and are protected under federal copyright laws. Printed materials cannot be reproduced in any form, by photocopy, microfilm, or any other means, or incorporated into any information system, electronic or mechanical, without the written permission of the copyright owner. Since honesty, honor, and integrity are expected of those entering medicine and of all Columbia Review students, failure to comply with any of these material use rules may result in permanent removal from e-Tutorials without refund, notification and complaint to your university administrators, federal and/or local legal authorities, medical school officials, the Association of American Medical Colleges (AAMC), as well as possible subsequentcriminal and civil legal action. The tuition for a single e-Tutorial session is $60. for students who have enrolled in Columbia Review's complete Live or Intensive Home Study Courses within the past twelve months, and $70. for all other students (those not currently enrolled in our complete courses). Our e-Tutor "3-PAK" allows you to pre-purchase three (3) separate e-Tutorials at a discounted price (one student can utilize all three e-Tutorials themselves or share the remaining two with one or two friends whose names, e-mail and home addresses with phone numbers are provided on a separate sheet that MUST be submitted with this application) as follows: $165. for complete Live and Intensive Home Study Course students and $195. for all other students. Students enrolling in our MCAT Essay e-Tutorials must have our current "Book 6"; thus, students who are not enrolled in our complete courses must also buy and briefly pre-read the Section 1 Writing Sample Studyguide within "Book 6" before beginning this e-Tutorial (Book 6 sold at discount for MCAT Essay e-Tutorial students only, reduced from $75. to $45. as a courtesy plus $10. shipping/handling fee within the USA); only those students officially enrolling together for MCAT Essay e-Tutor "3-PAK" are allowed to share use of one "Book 6", no other persons may use or be given this Book ever. All e-Tutorial sessions must be completed within six months of enrollent date. There are no refunds or exchanges on e-Tutorials or materials for any reason once your application has been accepted and processed by us.

Please complete Lines 1 - 17 below (completion of all lines is required): 1) Your name: 2) Your full e-mail address: 3) Your current home address: 4) Full shipping address: 5) Current phones: Your phone: Parent/Permanent: YOU MUST SIGN HERE: X________________________________________ DATE:_____________ PAGE ONE OF TWO 6) Your University: 7) Your Major, & Grad date: 8) When will you take the MCAT: 9) When will you apply to medical school: 10) Previous MCAT taken (if Yes: when, scores & how prepared): 11) What is your weakest MCAT subject area: 12) How did you hear about our program: 13) Method of payment: Check or Money Order (payable to: Columbia Review, mail with Application) Visa, MasterCard, Discover, American Express (complete below): Card Holder's Name: Card #: Expiration Date: Security Code (3 or 4 digits): Full Billing Address: 14) e-Tutorial Title (MCAT Essay or Med School Essay): 15) Total Charges: a) e-Tutorial type: Single or "3-PAK" (per above rates) = $ (attach names, addresses & phones if other "3-PAK" students) b) Book 6 @ $45 + $10 s/h for MCAT Essay e-Tutorial only = $ ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– c) Total Amount Now Due & Paid In Full = $ 16) Application for Enrollment Agreement (Print completed form, Sign, Date,
Fax or Mail to us): ALL OF THE INFORMATION I PROVIDED ABOVE IS TRUE AND CORRECT. I BOTH COMPLETELY UNDERSTAND AND PROMISE TO ABIDE BY ALL OF THE ABOVE TERMS OF THIS TWO PAGE
ENROLLMENT AGREEMENT. I ENCLOSE MY PAYMENT FOR ALL E-TUTOR SERVICES, MATERIALS AND SHIPPING/HANDLING FEES IN THE FORM OF A CHECK OR MONEY ORDER, OR AUTHORIZE
FULL PAYMENT USING THE CREDIT CARD INDICATED ABOVE IN LINE 13. Student Signature in Ink: X__________________________________________________ 17) Today's Date:

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NOTE: Upon receiving and processing your completed e-Tutor Application via FAX or MAIL,
our eTutors Program Office will e-mail you with welcome note, initial prep assignments, 
and more info.
Fax: 1-650-348-MCAT (-6228) • Phone:  1-650-343-0309 or 1-800-300-PREP                                       
Mail:  Columbia Review eTutors Program, 811 Oregon Ave, San Mateo, CA 94402-3307, USA
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Columbia Review Application for Enrollment: PREMED eTUTORS*