Course Number /Equipment rental request form. TWO WEEK NOTICE IS NEEDED!

Lead Instructor  * required
Date course is being held.  * required
Course being taught. Healthcare Provider - New Healthcare Provider - Renwal Heartsaver Adult CPR/AED Heartsaver Adult/Child CPR/AED Heartsaver Adult/Child/Infant CPR/AED Heartsaver First Aid Heartsaver First Aid w/ Adult CPR/AED Heartsaver First Aid w/ Adult/Child CPR/AED Heartsaver First Aid w/ Adult/Child/Infant CPR/AED Pediatric First Aid Pediatric First Aid w/ optional topics Pediatric First Aid w/ Adult/Child CPR Pediatric First Aid w/ optional topics & Adult/Child CPR/AED Pediatric First Aid w/ optional topics & Adult/Child/Infant CPR/AED Bloodborne Pathogen ACLS - New ACLS - Renewal PALS - New PALS - Renwal		If you are teaching an online course and would like to request online keys please provide number of keys you need. An invoice will be forwarded to you. Keys will not be released until invoice is paid. Keys are non refundable
Company name and address where course is being held. (If not at a company list private residence.)
Start time of course.  * required
Billing address (if different than course location)
Cards delivered to: E-cards emailed to students (must provide email addresses) CPST Office Mailed to instructor Mailed to course location CPST will e-mail you when cards are ready for pick up and confirm date and time of pick up. CPST will not be responsible and/or replace cards that are lost in the mail system.
Tenative # of students (you will not be billed on this #)
Will you be requesting equipment - Type in equipment needed. Type equipment needed here. Please note there is only DVD's for all courses		Equipment pick up location: Not applicable CPST Office
Each student needs a book for every course. If a book is not given to each student AHA completion cards can not be released as per AHA & CPST policies (effective 7-1-2013). Please contact CPST for AHA's library policies for HCP courses conducted at specific locations only. Books purchased thru CPST training center Books purchased thru distributer Libraried AHA Healthcare Provider books for Companies EMPLOYEES ONLY!	Please specify number of books you need to purchase or who you purchased your books thru if you ordered books on your own. Put library if you are using libraried books.  * required
E-mail/Phone #  * required