American Heart Association International Training Centre
American Heart Association International Training Centre
Baba Farid University of Health Sciences, Faridkot
Heart Saver/BLS/ACLS/PALS Provider Courses
Registration Form (to be filled in CAPITAL letters)
Registration Form (To be filled in CAPITAL letters)
Course : BLS/ACLS/Both BLS & ACLS/PALS (Tick as applicable)
Date of Course : _______________________
Participant Name(in capitals):
Father Name : Mother Name :
Department:
|Permanent Address |Correspondence Address |
| | |
| | |
|State : PIN: |State : PIN: |
|Qualification | |
|Mobile No. | |
|Alternate Phone : | |
|Email | |
Registration Fee (Non refundable)
|BLS Heart code (One Day) Rs. 3000/- (includes BLS heartcode , AHA Course Completion Card, Certificate, Tea / Coffee) |
|BLS and ACLS Course (2 days) Rs. 6000/- (includes BLS Heartcode online, ACLS E-book, 2 AHA Course completion cards, Certificate, Tea/Coffee) |
|PALS Course (2 days) Rs. 5000/- (Includes PALS Book, AHA Course completion card, Certificate, Tea/Coffee) |
|PAYMENT DETAILS |
|Cash / Bank Transfer No. Amount Bank Details Date |
| |
• For direct payment in bank : Oriental Bank of Commerce
Branch : BFUHS, FARIDKOT ACCOUNT NO : 160 120 11000 505
A/C NAME : BFUHS A/C AHA-ITC IFSC CODE : PUNB0160110
• Registration Form & Payment Transfer Details may be sent through post or email (bfuhs.itc@) to Dr. Ravinder Garg, Prof. & Head, Deptt of Medicine, GGS Medical College & Hospital, Faridkot – 151203 (Punjab) Mobile No. 9988863800
• Cash may be deposited with Mr. Sandeep Kumar (94640 09550), Pharmacy Officer, Department of Medicine, GGS Med. College & Hospital, Faridkot
• Registration is on first come first serve basis and the seats in each batch are limited.
• Please take ACLS pretest online on the website eccstudent and bring the printed copy of same alongwith. (Only for ACLS candidates)
• Also register itself on website before coming for the course.
• Contact Us :
website : bfuhs.ac.in/AHAITC
email : bfuhs.itc@
|For office Use Only |
| |
|BFUHS Receipt No ……………………………. Dated ……………….. |
| |
|Remarks : |
Signature of Candidate
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Passport size photograph
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