| Please be sure you are affiliated with a training center prior to submitting this application. |
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1) Application for *:
New Instructor
Certification Renewal
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| 2) Instructor Candidate Information *: |
| First Name: Last Name: |
| Email: |
| Address1: |
| Address2: |
| City: State/Province: Zip: |
| Country:
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| Phone (include country code, if international): |
| Fax (optional): |
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| 3) Have you ever had a license or certification suspended, revoked, or denied, including certification by any of the organizations listed below, or been convicted of a felony in any state? *: |
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Yes No
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If Yes, you may still be eligible for Instructor authorization, but you must provide a detailed explanation:
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| 4) Who is your Intended Audience(s) for CPR/AED for Coaches course? (Check all that apply) *:
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| 5) Training Center Affiliation *:
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| 6) Reciprocity: If you are currently a certified instructor for any of the following organizations, you may be exempt from completing Part B of the instructor training process. Please check all that apply.
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| 7) Instructor Agreement *:
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Effective on the date of application, I understand and agree for myself;
a) That approval and authorization as an ASEP CPR/AED for Coaches Instructor is a privilege, not a right and may be revoked.
b) To teach all programs and operate in accordance with the most recent and applicable version of the Instructor Guide and Training Center Administrative Manual.
If you agree with these statements, click here.
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