APPLICATION FOR ASHI INSTRUCTOR AUTHORIZATION

"Grandfather" instructor authorizations can be granted to instructor candidates whom possess a license as EMT's, paramedics, nurses, or other licensed medical professionals that are currently certified as an instructor in another national training program.

Instructor Development Courses are available through Training Centers for instructor candidates needing further development. Authorized instructors may complete authorized training programs and provide nationally accepted completion cards for first aid training. Instructor candidates interested in obtaining instructor authorization should complete this application and forward to Less Stress Instructional Services, 138 Buena Vista Ave, Hawthorne, NJ 07506 or fax to (973) 427-6090.

Name : _____________________________________________________

Address:: _____________________________________________________

City: ______________________________ State: ________ Zip: ____________________

Phone (work): ______________________ (home): ____________________________

E-mail: ___________________________________________

Circle Certifications which apply:

EMT Basic ... EMT Intermediate ... EMT Paramedic ... RN ... LPN ... MD/DO

ARC Instructor . . AHA Instructor . . NSC Instructor . . AHA Instructor-Trainer

Other:______________________________________________________________________

**** ATTACH A COPY OF ANY CREDENTIALS YOU WISH TO HAVE CONSIDERED ****

Payment Type ($15.00 payable to Less Stress): ___Check ___Money Order ___VISA ___Mastercard

I guarantee the accuracy of the information I have provided is true to the best of my knowledge. I authorize the charge of $15.00 to the below VISA or Mastercard credit card, or I have included a check or money order with this form.

Card number: _ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _ Expiration Date: _ _ - _ _

Signature: __________________________________________ Date: ____________________

Your authorization will be reviewed by the ASHI Basic First Aid Committee. Your application acceptance will be sent to the address listed above. To complete your instructor authorization: 1. Order Instructor Manual/Authorization Form 2. Read ASHI Program Guidelines and ASHI Instructor Agreement 3. Sign and return agreement to ASHI 4. For IT status, please request IT application. Upon completion of this process, instructor will be eligible to issue nationally accepted ASHI program completion cards for the authorization period of three years.