Instructor Records Transfer Request


American Heart Association Emergency Cardiovascular Care Programs

Instructor Records Transfer Request

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Instructions : When an instructor wants to transfer to a different Training Center (TC), this form must be completed by the instructor, the transferring TC Coordinator (TCC) and the accepting TCC. The transferring TCC returns the completed form with the instructor’s records to the accepting TCC. The accepting TCC contacts the instructor when the transfer is complete.  

SECTION 1:
To be completed by the TCC of the accepting TC and sent or given to the transferring instructor.

Our TC is willing to accept the instructor named below as an instructor at our TC.

Instructor's Name: Instructor ID:

We agree to keep and maintain all instructor records in accordance with our TC Agreement with the AHA and the Program Administration Manual.

TC Name: LifeTek, Inc. Training Center ID: WA15093
TC address: 2021 East College Way, Suite 214
City: Mt. Vernon State: WA Zip: 98273 Phone: (360) 416-8239
Signature of TCC: See e-signature of LifeTek, Inc. representative at bottom of document Date: November 29, 2020
SECTION 2:
To be completed by the instructor who is transferring and sent or given to the transferring TCC.
I, , Instructor ID# , authorize the transfer of my
instructor records for
from TC name: TC ID#:
to TC name: LifeTek,Inc. TC ID#: WA15093
Instructor's home address:
Home phone: Work phone:
SECTION 3:
To be completed by the current TCC and sent with the records being transferred.

Note: All applicable instructor records, as outlined in the Program Administration Manual, must be transferred. The transferring TC must keep copies of all transferred records for 3 years .
TC name: TC ID#:
TC address:
TC address:
City: State: Zip: Phone:
Signature of TCC: Date:

Leave this empty:

Signature arrow

Signed by Sylvia Thompson
Signed On: November 13, 2020

Signature Certificate
Document name: Instructor Records Transfer Request
lock iconUnique Document ID: 407ad472aaeb8301cae6d3cbe14ba533703c0ca0
Timestamp Audit
October 26, 2020 4:05 pm MSTInstructor Records Transfer Request Uploaded by Sylvia Thompson - southsound@lifetekinc.com IP 174.126.133.26