Form_3: BLUECARDINT 1st Responder Module Registration Form MASTER

CANADIAN, EUROPEAN, AND ASIAN
FIRE DEPARTMENT MEMBERS
Blue Card 1st Responder Module Registration Form
Department Information
What is the name of the Fire Department or Company? *

Department Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Department Administrator
First Name *
Last Name: *
E-mail *
How many Course Registrations *
Maximum 10 per Submission
Registrations for the Blue Card 1st Responder Overview
Module are $60.00 USD/Registrant. For 11 or more
registrations, email registrations@AOYSFireTraining.com
for direct invoicing.

Blue Card 1st Responder Module Registrant No. 1
Blue Card 1st Responder Module Registrant No. 1 Information
First Name: *
Last Name: *
Department Rank: *
Contact Email Address *

Blue Card 1st Responder Module Registrant No. 2
Blue Card 1st Responder Module Registrant No. 2 Information
First Name: *
Last Name: *
Department Rank: *
Contact Email Address *

Blue Card 1st Responder Module Registrant No. 3
Blue Card 1st Responder Module Registrant No. 3 Information
First Name: *
Last Name: *
Department Rank: *
Contact Email Address *

Blue Card 1st Responder Module Registrant No. 4
Blue Card 1st Responder Module Registrant No. 4 Information
First Name: *
Last Name: *
Department Rank: *
Contact Email Address *

Blue Card 1st Responder Module Registrant No. 5
Blue Card 1st Responder Module Registrant No. 5 Information
First Name: *
Last Name: *
Department Rank: *
Contact Email Address *

Blue Card 1st Responder Module Registrant No. 6
Blue Card 1st Responder Module Registrant No. 6 Information
First Name: *
Last Name: *
Department Rank: *
Contact Email Address *

Blue Card 1st Responder Module Registrant No. 7
Blue Card 1st Responder Module Registrant No. 7 Information
First Name: *
Last Name: *
Department Rank: *
Contact Email Address *

Blue Card 1st Responder Module Registrant No. 8
Blue Card 1st Responder Module Registrant No. 8 Information
First Name: *
Last Name: *
Department Rank: *
Contact Email Address *

Blue Card 1st Responder Module Registrant No. 9
Blue Card 1st Responder Module Registrant No. 9 Information
First Name: *
Last Name: *
Department Rank: *
Contact Email Address *

Blue Card 1st Responder Module Registrant No. 10
Blue Card 1st Responder Module Registrant No. 10 Information
First Name: *
Last Name: *
Department Rank: *
Contact Email Address *

STOPPER
Billing Summary
Method of Payment *
Billing Province (if Canada) *
Subtotal
US Funds Excluding GST/HST
Total Purchase
US Funds GST/HST Included
Credit Card purchases include an additional 4% transfer fee.
Total w/Credit Card Charge
US Funds GST/HST + 4% Transfer Fee
Purchase Order No. *
NOTE: All PO Orders are subject to verification.

Credit Card Payment

USD Total Payment (GST/HST & Credit Card Fee Included)

Payment Method

	What is PayPal?

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty: