First Name:    Last Name:

Address:

City:   State:   Zip Code:

Home Phone:   Work Phone:   Fax Number:

E-Mail Address:

Level of Licensure: Please make a selection Paramedic Intermediate Basic RN M.D. D.O. RN/Paramedic RN/EMT Other

Re-enter your Email Address:

County that you live in:

Instructor Status: (Type of instructor card that you currently have)

Please make a selection Advanced BLTS Instructor Basic BTLS Instructor Advanced & Pediatric BTLS Instructor

Do you currently hold BTLS Affiliate Faculty Status? Yes or No

If yes, do you want to continue to serve as a BTLS Affiliate Faculty? Yes or No

Have you served as course coordinated for a BTLS course within the past 2 years? Yes or No

As a BTLS Instructor, you are required to instruct three courses during your three year instructor period.  Please complete the form below with the appropriate information.

I was unable to teach the required courses (please detail why you could not meet the above requirements below ie, no courses scheduled, courses cancelled, military leave, etc. below).