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REQUEST FOR DUPLICATE CARDIn order to receive a duplicate card all information below must be completed and submitted to: IMMC / Simulation Center, 1200 Pleasant, Des Moines IA 50309 or you may email to UPHDM_CTC@ or fax to 515-241-5038.I ____________________________(your name) am requesting a duplicate copy of my ______________________(BLS, Heartsaver, ACLS or PALS) card. I took the class on ________________(exact date) and my instructor’s name was ___________________ (instructor name).Please email the card to :Phone number__________________________________________________________There is a $15.00 charge for BLS Cards. $25.00 charge for Heartsaver Cards. $25.00 charge for Advanced (ACLS, PALS, or PEARS) or Instructor Cards:Enclosed is a check _____________Or you may call or fax me with your credit card information at:Carly Hansen515-241-6811Fax 515-241-5038Signature/Date__________________________________________________________Revised 8/10/18 KSD ................
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