First Name:    Last Name:

Please enter the address where you want Alabama BTLS correspondence sent to:

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 BTLS 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.  If you were not able to complete your teaching requirements, please check the box below and enter a detailed reason(s) why you could not meet the teaching requirements.

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).