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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