AHA COURSE REGISTRATION/PAYMENT VERIFICATION FORMFAX TO: 909 558-0967 or EMAIL TO: simulationcenter@llu.edu BLS ONLINE COURSE + SKILLS TESTING = $55 ACLS ONLINE COURSE + SKILLS TEST
Trang 1AHA COURSE REGISTRATION/PAYMENT VERIFICATION FORM
FAX TO: (909) 558-0967 or EMAIL TO: simulationcenter@llu.edu
BLS
ONLINE COURSE + SKILLS TESTING = $55
ACLS
ONLINE COURSE + SKILLS TESTING = $175
PALS
ONLINE COURSE + SKILLS TESTING = $175
*Please note, in order to take ACLS or PALS you need a current BLS card If you don’t have one, register for BLS also*
Loma Linda University Health Employees: Loma Linda University Employees:
LLUH 14-Digit Account#/Cost Center LLU Cost Center / Fund & Org #
Total amount to be charged Total amount to be charged
Signature of Authorizing Department Head* Signature of Authorizing Department Head*
*Signature above authorizes Loma Linda University Medical Simulation Center to charge via Journal Voucher the above-noted department and/or unit for BLS, ACLS, and PALS certification provided for above-said employee/student.
*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~* The Medical Simulation Center also accepts Visa or MC If you are paying by credit card, please fill in the information below:
- - - Visa MC / $
Credit Card Number Exp Date Amount
Signature of Card Holder
*Please note, all sales are final
LOMA LINDA UNIVERSITY |SOM| Medical Simulation Center
Office: (909) 558-7208, Ext: 87208, Fax: (909) 558-0967