Replacement Card Order Form printable pdf download

Replacement Card Order Form

619-469-7109 / 888-999-6631

NEW: 7435 University Ave., #104, La Mesa, CA 91942

Replacement Card Order Form

This information may be phoned in to 619-469-7109, emailed in to , or brought in to AmeriMed

CPR Training 7435 University Ave., #104, La Mesa, CA 91942 during normal business hours (Mon-Fri, 9am-4pm). You

may also mail it in to AmeriMed CPR Training 7435 University Ave., #104, La Mesa, CA 91942

Name of student: _____________________________________________

Date of class: ____________________

Course location: ______________________________________ Instructor’s name: ______________________________

Class taken / certificate needed:

 AmeriMed BASIC CPR/AED

$8.00

 AmeriMed BASIC FIRST AID

$8.00

 AmeriMed BASIC CPR/AED/FIRST AID

$10.00

________________________

 AmeriMed EMSA CPR/AED

$10.00

 AmeriMed EMSA FIRST AID

$10.00

 AmeriMed EMSA CPR/AED/FIRST AID

$20.00

 AmeriMed EMSA Preventive Health Practices certificate

$10.00

_________________________

 American Heart Association BLS for Healthcare Provider

$10.00

 American Heart Association HEARTSAVER CPR AED

$10.00

 American Heart Association HEARTSAVER CPR AED FIRST AID

$20.00

 American Heart Association HEARTSAVER PEDIATRIC FIRST AID

$20.00

We accept VISA, MasterCard or Discover (NO PERSONAL CHECKS):

Card number _____________________________________________________________________________________

Expiration date _____________ 3 digit security code (on back): ___________

Amount to charge: ___________

Billing address including ZIP:

_________________________________________________________________________________________________

Phone number: ________________________________ Email address: _______________________________________

Mailing address (if different):

_________________________________________________________________________________________________

Replacement Card Order Form