ORDER FORM for
AHA CERTIFICATION CENTER PROGRAM LOGO
A greement for Placing the O rder: I understand that only currently certified individuals may submit this order form and that this order will be processed after currency of my certification has been verified for the program logo I am ordering. The logo may be used as artwork for business cards or stationary as long as I remain certified and continue to abide by the AHA Code of Conduct and the American Hospital Association Certification Center (AHA-CC) Guidelines for use of the AHA-CC Certification Marks If I misrepresent any of the AHA Certification Center programs, designations, or the logos in any manner, I agree to cease and desist that practice. If it is determined that my certification has expired and payment for the logo has been processed, I will receive a refund of the payment in the manner in which it was submitted. By submitting this request for the logo, I agree to the above and certify that I have read and agree to abide by the AHA-CC Guidelines for use the AHA-CC Certification Marks.
Signature: ________________________________ Date: _______________
Mailing Address : □ Business □ Residence (check one)
Name: ______________________________ Certificate Number: _______________
Title: _______________________________ Organization: _____________________
Street Address: ____________________________________________________________
City _______________________ State _______________ Zip Code ________
Daytime Phone ( ) ___ - ______ email: _________________________________
Fee: $10 per logo ordered. Logo will be provided in eps & jpg formats. Check the certification you currently have.
□ CHC Logo □ CHESP Logo □ CHFM Logo □ CHHR Logo □ CMRP Logo □ CPHRM Logo
SAMPLE Business Card
Payment Method (check one)
□ Check. Make payable to American Hospital Associ ation
□ Credit Card Payment. Complete the following: □ Visa □ MasterCard □ American Express
Credit Card Number: _________________________________ Expiration Date: ______________
Name as it Appears on Card: ___________________________ Signature: ___________________________ (Required for processing Credit Card Orders)
Submit to : AHA Certification Center; Certification Logo Order, P.O. Box 75315; Chicago, IL 60675-3715 or FAX to 312-422-3609 (Logo will be emailed in eps & jpg format s. P ayment processing and order fulfillment generally takes about three weeks . )
Questions? Call 312.422.3702 or send inquiry to
Rev January 2014