payment-registration-form-llu-msc

AHA COURSE REGISTRATION/PAYMENT VERIFICATION FORM FAX TO: (909) 558-0967 or EMAIL TO: simulationcenter@llu.edu Name of Employee/Student Employee/Student# Date E-mail address 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* *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: - Credit Card Number - Visa MC / Exp Date Signature of Card Holder *Please note, all sales are final LOMA LINDA UNIVERSITY |SOM| Medical Simulation Center 24760 Stewart Street, Centennial Complex 4th Floor, Loma Linda, CA 92350 Office: (909) 558-7208, Ext: 87208, Fax: (909) 558-0967 $ Amount