Missouri Credentialing Board
(573) 616-2300 www.missouricb.com 428 E. Capitol, 2
nd
Floor
(573) 616-2303 (FAX) email: help@missouricb.com Jefferson City, MO 65101
March 2021 MARS Program Application
Please fill out this form and e-mail to MCB staff at help@missouricb.com, fax to 573-616-2303 or
mail to MCB, 428 E. Capitol Ave., 2
nd
Floor, Jefferson City, MO 65101 by March 1
st
, 2021. The
total cost of the program is $100.00 and must be paid prior to starting the program. Once the
program starts, no refunds will be made for any reason. Please type or write neatly and all
information must be included.
Name_________________________________________________________________________
Best Mailing Address:_____________________________________________________________
City: __________________________________ County: _________________________
State: _________________________________ Zip: ____________________________
Home: (_______)_________-_______________ Work: (_______)__________-_______________
Cell: (_______)___________-_______________
SS Number: ____________________________ Birthdate: ______________________________
Email Address: _________________________________________________________________
Signature: ______________________________________________________________________
Date: ____________________________
Best way to contact you: __________________________________________________________
Please mark which live training time you would like to attend on Friday March 5
th
:
1. 9:00-11:00: ___________________
2. 2:00-4:00: ____________________
To pay by Credit Card, please provide Number, Expiration Date and 3 Digit Verification Code:
Number: ____________________________ Exp. Date: ___________ Ver. Code: _________
Please Note:
This program will start March 5
th
, 2021 and will be completed June 11, 2021.
click to sign
signature
click to edit
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