Form

Please note that this form serves only as a temporary reservation. Slots are limited and we are on a first-come-first-serve basis. To guarantee your slot reservation, you must follow up a call to get our bank account details and other payment options. You must pay at least 50% of the course fee as soon as possible prior to the commencement of the course.

Please call our office at (02)5630784 or text 09295042162/09215341128 for payment options/details and to check whether the slots are still available.

Date today*

- Month - Day Year

Full Name*

First Name Middle Name Last Name Suffix

Nickname*

Age*

Sex*

Male Female

Nationality*

Mailing Address:*

E-mail Address:*

Mobile No.*

Telephone No.

- Area Code Phone Number

Fax No.

- Area Code Phone Number

Occupation / Profession*

Other, please specify, occupation / profession*

Current Affiliation / Agency

Contact No.:

Email Address:

Examinations taken:*

Nursing Board Medical Board NLEX / NCLEX Other

Other, please specify:

RN U.S. License*

With US License No US License

RN U.S. License No.*

RN U.S. State:*

License Status*

Active Expired For renewal

How did you find us?*

Website / Forums Newspapers Flyers / Brochures Email Friends / Relatives / Colleagues Hospitals / Institutions Other

Other, please specify, how did you find us?*

AHA Courses to take

Date of Course (BLS)*

Date of Course (ACLS)*

Date of Course (PALS)*

Preferred Date (Heartsaver CPR AED)*

- Month - Day Year

Tentative Checkoff date (Heartcode BLS):*

- Month - Day Year

Tentative Checkoff date (Heartcode ACLS):*

- Month - Day Year

Preferred Date (Heartsaver CPR AED w/ Firstaid)*

- Month - Day Year

Preferred Date (BLS Instructor Course)*

- Month - Day Year

Preferred Date (ACLS Instructor Course)*

- Month - Day Year

Preferred Date (PALS Instructor Course)*

- Month - Day Year

Continuing Education Courses to take

IV Therapy and Phlebotomy Physical Assessment 12 Lead ECG Interpretation HIV / OSHA Bloodborne Pathogens Prevention of Medication Errors Domestic Violence

Preferred Date (IVTP)*

- Month - Day Year

Preferred Date (PA)*

- Month - Day Year

Preferred Date (12Lead)*

- Month - Day Year

Preferred Date (HIV)*

- Month - Day Year

Preferred Date (PME)*

- Month - Day Year

Preferred Date (DV)*

- Month - Day Year

Comment(s):

RESERVATION AND CANCELLATION POLICY

RESERVATION

Reservation for course(s) can be made online or in our training center by submitting accomplished registration form.
Reservation will only be confirmed upon payment of at least 50% deposit three (3) days prior to the course.
Payments or deposit slips should be received through fax, email, or text message three (3) days prior to the course and should be acknowledged / confirmed by the Global CE staff.

CANCELLATION

Cancellation done seven (7) days prior to the course: 100% refund (cost of the textbook is non-refundable).
Cancellation done six (6) to three (3) days prior to the course: 50% refund (cost of the textbook is non-refundable).
Cancellation done two (2) days prior to the course or "No show/No attendance": No refunds.

RESCHEDULING

You may reschedule or have a substitute only within two (2) days prior to the course. Rescheduling should be done within two (2) months from the date of your course.
Rescheduling and substitution must be done in writing (via email, phone/SMS or handwritten with signature and must be acknowledged by the staff). There will be also a rescheduling fee of Five Hundred Pesos (P500.00) .

Contact Information

Global CE Provider of America, Inc.
2230 Pedro Gil Street, Santa Ana, Manila, Philippines 1009
Contact Nos. (02)563-0784 Mobile Nos. 639295042162 / 639215341128
Email: gami_phil@att.net
Website: http://globalamericanmedical.com/globalce

_______________________________________________________________

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Registration Form