Alignment Request Form

I understand this form must be completed in order to transfer my instructor status. I confirm that I have all the required materials needed to teach the disciplines I am requesting transfer for. I acknowledge that I will comply with the AHA guidelines, policies and procedures. *

I confirm that I have read, understand and accept the terms of the statement above.

Your Information

Your Full Name *

Enter your Instructor ID *

Enter your Street Address *

City, State zip *

Home Phone *

Work phone *

Enter todays date * +

Enter Your Email Address *

Enter information about the center you are transfering from

Enter Name of your Previous Training Center *

Enter your previous TC ID number (From your Instructor card) *

Enter Previous TC Street Address *

Enter City *

Enter State *

Enter Zip *

Previous TC Phone number *

Previous TC Fax Number *

Instructor Acknowldgement Section

Heartsaver	BLS
ACLS	ACLS-EP
PALS	PEARS