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["MONTESSORI INSTITUTE OF AMERICA "]
["SUMMARY COVER PAGE"]
[null,"Instructions"]
[null,"1. Using boxes on left side, place an X in all items that are included in this submission and payment. Leave blank any boxes that do not correspond with the current payment."]
[null,"2. For underlined fields on right side, enter a quantity."]
[null,"3. All sections with * are required. Double check this form before submitting."]
["SECTION 1 - TEP INFORMATION *"]
["Legal Name of TEP *                                                                                         ",{"$nulls":5},"Today's Date (month/dd/yy) *                                                  "]
["Program Name *                                                                                                                                                                          ",{"$nulls":5},"Name of Person Submitting form to MIA:"]
["SECTION 2 - FEES PAID *",{"$nulls":8},"Line Totals"]
["TEP Application Options"]
[null,"Initial TEP Certification of one Program Level",{"$nulls":4},"Program Level:",null,"x  $1,000"]
[null,null,"Initial TEP Certification of ADDITIONAL  Program Level",{"$nulls":3},"Quantity:",null,"x    $ 500"]
[null,"Renewal TEP Certification of one Program Level",{"$nulls":4},"Program Level:",null,"x    $ 200"]
[null,null,"Renewal TEP Certification of ADDITIONAL Program Level",{"$nulls":3},"Quantity:",null,"x    $ 100"]
[null,"Deferrment: Initial TEP Certification (year 1)",{"$nulls":6},"x    $ 400"]
[null,null,"Deferrment: Initial TEP Certification (year 2 or 3)",{"$nulls":5},"x    $ 300"]
["Registration & Graduation Fees"]
[null,"Registration Fee for Teacher Training",{"$nulls":4},"Quantity:",null,"x    $ 150"]
[null,"Registration Fee for Classroom Assistant (Toddler, Early Childhood)",{"$nulls":4},"Quantity:",null,"x     $  15"]
[null,"Registration Fee for Infant Care Assistant",{"$nulls":4},"Quantity:",null,"x     $  15"]
[null,"Graduation Fees (Teacher Applications) for Teacher Training",{"$nulls":4},"Quantity:",null,"x    $ 150"]
[null,"Graduation Fees for Classroom Assistant (Toddler, Early Childhood)",{"$nulls":4},"Quantity:",null,"x      $ 20"]
[null,"Graduation Fees for Infant Care Assistant",{"$nulls":4},"Quantity:",null,"x      $ 20"]
[null,"Training Of Trainers Registration Fee (non-refundable)",{"$nulls":4},"Quantity:",null,"x    $ 100"]
[null,"Training Of Trainers Tuition Fee",{"$nulls":4},"Quantity:",null,"x  $1,900"]
[null,"Training of Trainers Tuition Deferred Payment Plan                                                 (3 payments over 12months) *Deferred Payment Contract Required",{"$nulls":4},"What Number Payment is this:",null,"x $ 633.33"]
[]
["Practicum Site Option"]
[null,"Practicum Sites requesting Certificate and Website Presence",{"$nulls":4},"Quantity:",null,"x     $ 100"]
[null,"Practicum Sites requesting 3-Year Certificate and Website Presence",{"$nulls":4},"Quantity:",null,"x     $ 250"]
[]
[{"$nulls":7},"Final Grand Total *"]
["SECTION 3 - PAYMENT INFORMATION - How are you paying? (Check box)*"]
[null,"On MIA website at www.mia-world.org/shop"]
[null,"Requesting formal invoice before making payment",{"$nulls":3},"Email address to send invoice:"]
[null,"By Credit Card (US only)",null,"Card Number",null,null,"Expiration (mm/yy)",null,"CVC"]
[null,"By Check",null,"Check Number"]
[null,"By Money Order"]