Affiliate Faculty Application Form
To be completed by prospective affiliate faculty
Affiliate Faculty Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Date of application
-
Month
-
Day
Year
Date
Named Courses Applied For
Cardiac First Response Community
Cardiac First Response Advanced
First Aid Response
Emergency First Response
Rationale for application as affiliate faculty
Reference
Please include name and contact details for a suitable reference as per DX2 affiliate faculty guidelines
Checklist for progression to stage 2
Fully completed application form
Instructor Certification for each named course
PI & PL Insurance
Affiliate Faculty Guidelines read & understood
By Signing This Document The Prospective Affiliate Confirms All of the above to be true and accurate
*
Submit
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