CPR Consultants, Inc
CPR Consultants, Inc. AHA Training Center
Instructor Renewal Form 2017
Mail to: 7404-G Chapel Hill Road, Raleigh, NC 27607,
Email to: yakisha@, or fax: 919-235-0842
Office Number: 919-850-9295 / 866-990-CPRC
|NAME: __________________________________________________________________ |
|ADDRESS: _______________________________________________________________ |
|________________________________________________________________________ |
|CITY: _________________________________ |ZIP: ____________________________ |
|CELL PHONE: __________________________ |HOME PHONE: ___________________ |
|WORK PHONE: _________________________ |OTHER: _________________________ |
|EMAIL ADDRESS: __________________________________________________________ |
*We recommend home address versus your employer, and a current email to send you updates from the AHA. Generally, all communications from us are through email. Please keep us updated of any email changes.
American Heart Association Instructor Type
|BLS Instructor | |
|Heartsaver Instructor (Check this only if you are not a BLS Instructor) | |
|First Aid Instructor | |
|ACLS Instructor | |
|PALS Instructor | |
|Faculty (BLS, ACLS and/or PALS) | |
|ACLS EP Instructor | |
CPR Consultants, Inc. Instructor Dues are $50.00/yearly and are due by February 28, 2017. On March 1st dues increase to $75.00, dues increase again on April 1st to $100 and lastly to $150 on May 1st. After June 1st, your instructor status will be deactivated from our Training Center.
Three payment options are available for 2017 Dues Renewal
Check
Number: ______________ Amount: ______________
Credit Card
Number (VISA/MC/AMEX/DISCOVER): ________________________________________________________________
Amt: __________ Exp. Date: ___________ CVV Code: __________
PO
PO information must accompany this form and payment must be received in our office on or before the due date to avoid increase fees.
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