Name

Level of Certification (ex., EMT-P, EMT-B, etc.)

Home Address

County

City

State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP Code

Telephone

Email Address

Instructor Type
Basic
Advanced

Instructor Card Expiration Date

As an ITLS instructor, you are required to instruct one course per year. Please complete the field below with the appropriate information. If this section is left incomplete, your instructor card expiration will not be extended.

Instructor cards will be reissued with an expiration date extended to December 31, 2007.

Instructor Course Information
Please list course date, course location, lecture assignment, and skills station for the course taught. If you have instructed multiple courses within the past year, please list this information for
each course taught.