Scheduled By: Lee Hines Mike Holloway Dana Smith    Info Request only, Dana to Contact to Follow Up

Date of Class:    Day : Saturday Sunday Monday Tuesday Wednesday Thursday Friday Unit Day: 1 2 3 (If Known)

Time of Class:

Business Name:

Billing Street Address:

Billing City: Billing State: Billing Zip Code:

Contact Name:   Contact Phone

Contact EMAIL: Contact FAX:

Location of Class

Street Address of Class

Type of Class CPR - Adult CPR - Pediatric CPR - Adult and Pediatric CPR - Professional First Aid AED Communicable Disease Child Abuse CE Class Other Hold Ctrl and L Mouse Click to add multiple selections

                    If CE Class or Other, Name of Class:

Number of People in Class:

Proposed Length of Class: in Hours

Quoted Price for Class: $  Cancellation Policy Reviewed?   Price Sheet Link

Instructor Assigned to Class:

Second Instructor Assigned (if Required):

Class Number Assigned:
                                      DATE of CLASS/Scheduler Initials/# of Class that day
                                      Example : 010104DS1, 1st class Dana sets up on 1-1-04

Notes:

Complete all Above information and Submit.

If you can not assign an instructor submit and check with Dana to insure he gets email notification of class.  It does us no good to set up a class and forget to follow up on it.