LLC

HEART ACLS Course Registration Form (Rev. 1/08)

Print & complete this form, then mail to address below with payment.

Name: _________________________________

Title:  __________________________________

Organization: ____________________________    Dept: ________________

Mailing Address: _________________________________________________

Address Cont'd:  _________________________________________________

City: ____________________     State: __________  Zip Code: __________

Work Phone: (         ) ________- _________    Ext. _______

Home Phone: (        ) ________- _________   

Fax: _____________________

E-mail: _________________________  REQUIRED - We'll e-mail your registration info !

Licensure:  _____  D.D.S.     _____ EMT-P        _____  M.D.    _____  R.N.

                _____  D.O.       _____ L.P.N.        _____  P.A.     _____  R.T.

                _____  Other (specify) _____________________

Please enroll me in:

ACLS Initial Provider (16 Hr.)         ACLS Refresher (8 Hr.)

                                                             (Forward copy of card with form)

I am interested in a  (circle)  REFRESHER    PROVIDER  Course

More to come .......

Payment:   ___   ACLS Provider (16 Hr) with text ($145.00)

                ___   ACLS Provider (16 Hr.) without text ($108.00)

                ___   ACLS Renewal with text ($102.00)

                ___   ACLS Renewal without textbook ($65.00)

                ___   Late Registration fee, if 7 or less days to course ($10.00)

                ** As of Aug. 31, 2006, all students are required to have a current 2006 ACLS     

                    textbook & CD to use before and during the class.

                **Payment must accompany registration

Make check or money order to HEART Consultants & mail form and payment to:

HEART Consultants, 109 Pine Hollow, Chardon, OH  44024

____  My check or money order will serve as my receipt of payment for this course.

____  I require an additional receipt of payment for this course.

A confirmation letter, and a text with CD/Pretest (if requested) will be forwarded to you by e-mail upon receipt of this registration form and payment.  CD Pre-tests are to be completed prior to the first class day.  Any enrollee who fails to cancel prior to the first day of the course, forfeits the entire registration fee.

I hearby acknowledge that I have read this form, and that by submitting the form, I acknowledge the guidelines and policies that are posted on the HEARTCO.COM website.  I further agree to these terms.

Signed: ___________________________   Date: ___________________