You must have JavaScript enabled to use this form. First Name * Last Name * Street Address * City * State * Postal Code * Country * Email Address * Primary Phone * Secondary Phone Course(s) for which you are applying for reciprocity: * Community CPR & AED Health Care Provider Basic Life Support Standard First Aid Preventing Bloodborne Pathogens Please indicate the E&A Safety & Health Services course(s) for which you are applying for reciprocity: Eligibility: * American Heart Association instructor American Red Cross instructor Emergency Care & Safety instructor Ellis & Associates instructor EMS instructor Fire instructor Health and Safety Institute (ASHI / Medic First Aid) Instructor Law enforcement instructor National Safety Council instructor Other: corporate training or professional educator Other: physician, nurse, PA, paramedic, EMT I believe I am eligible to receive instructor reciprocity based on my credentials below (Click all that apply): Proof of Credentials: * Upload Please upload proof of your credentialsFiles must be less than 12 MB.Allowed file types: jpg jpeg png pdf doc docx. Comments: Please place additional Comments below: Leave this field blank Submit
