Affiliation Request Form

This form will provide us with requests for affiliation from training centers around the 
country.  Please complete the form and someone from our office will contact you.

Basic affiliation requirements:

• Should have day, evening, and weekend availability

• Must have access to 2-3 other instructors for larger assignments

• Must own/have access to 10 adult and 10 infant manikins

• Must have ability to provide sanitary (non-alcohol wipe method) training via removable manikin face and/or 
  faceshield lungbag system

• Must be able to provide at least AHA and ASHI programs

• Must be committed to providing services according to the guidelines of the particular program we are 
  teaching.  We are not interested in "quicky one hour" CPR classes.

Company/Group Name  	 	:
Contact        			:
City           			:
State                      			:
Zip                        			:
Phone           			:
E-Mail Address  			:

What kind of training have you been providing in the last year?  List audiences and volume.

Do you currently sell AED's?  If so what type?

How far (how many minutes) are you willing to travel as your primary service area?

Please tell us (type and quantity) of your training equipment.

How can you be reached during daytime hours?

How many instructors/what type of instructors can you access for a training job?

Please list any other details about your agency you think we should know about:



We will contact you within 24 business hours of this email.