Acute Care
Education Systems Inc.
2500 W
Higgins Rd suite 1278
Hoffman
Estates, Illinois 60169
Phone: (847)
882-7076
Fax: (847)
882-2515
E-mail: acute_care@sbcglobal.net
1.
Complete the information section below.
2.
Attach a copy FRONT
AND BACK of all current American Heart Association instructor
cards.
3.
Forward these documents to the address listed above along with
$60 for the Standard Membership
Payment
can be made using a check, money order, Visa or Mastercard.
I
am currently a (check all that apply):
____
BLS Instructor EXP. DATE: _______ ____ ACLS Instructor EXP. DATE: _______
____
BLS Instructor-Trainer EXP. DATE: _______
____ PALS Instructor EXP. DATE: _______
PLEASE
PRINT
Name:
___________________________________________ SS# _________________________
Address:
_______________________________________________________________________
City/State/ZIP:
__________________________________________________________________
Phone:
__________________________________ Fax: __________________________________
Pager:
__________________________________ E-mail: ________________________________
Position/Profession:
______________________________________________________________
Employer:
________________________________ Unit/Area: ____________________________
Signature:
__________________________________________ Date:_______________________
Applying
for: _____ Standard Membership ($60/year)
Payment
Method: ______Check _____ Money Order ______ Visa/MasterCard
Card Number:
_______________________________________________
Expiration Date:
___________________