On-line Instructor Request Form

St. Clair County Chapter of the American Red Cross

Health and Safety Services    OFF - SITE Instructor/Customer  Request for supplies.  PICK UP TIMES ARE DURING BUSINESS HOURS  9 -3PM

FORM MUST BE TURN IN 2 WEEKS PRIOR TO CLASS. NO EXCEPTIONS.

Please fill out the form below:

General Information

Person Ordering:

Company:

E-mail address:

Address

Phone Number:
Ext:

Contact Person :


Payment Method
Cash    Check    Check Number

P.O.#

Billed    To Whom?   

        Address        

Instructor Information

Date Instructor will pick up equipment: Time:

Date Instructor will Return equipment: Time:

    Equipment Order

        Repair and maintenance is the responsibility of everyone.  Please advise our Health and Safety Office if there is a problem with the equipment

                          Amount                Price                            Amount         Price

    Manikins:     Adult:            Face Shields:       

                          Infant:           Alcohol Pads:       

              Aktar System:     

      First Aid Supply Box:      First Aid Trainer Kits:    

                                            TOTAL Price for Equipment  :    

    Each student is required to have a book, even if the student audits a class.     DO NOT RECYCLE BOOKS                          

   Book Order 

 Book:  Quantity: Price:

            Quantity: Price:    

            Quantity: Price:   

               Quantity: Price:  

                                                                TOTAL Price for Books: 

    Student Certificates: (Some classes require more than one certificate)IF NO CARD  ARE  ISSUED TO  A STUDENT, IT IS A AUDIT. $5.00 per student on sheet for Administration Fee.

    Name of Certificate:                   Quantity:             

           

           

                                                 TOTAL Price for Certificates:  

   Video Tapes:

Name of Video:                           Quantity:             Prices

           

             

             

                                                        TOTAL Price  for Videos:   

                                                           PRICE  GRAND TOTAL 

REMEMBER: Late Fees applies after the 5th work day on all equipment  rented.

Do you have any other questions that we can help you with?

No Refunds or Exchanges

By submitting this form, I am indicating that I have been authorized to make this purchase/order and that I agree to abide by the rules and regulations of the instructor's agreement and chapter rules.

Chapter Communications
Copyright © 2002 St. Clair County Chapter American Red Cross. All rights reserved.
Revised: 06/13/06.