AFFILIATE EMAIL, INTERNET ACCESS, and LINK FORM

Email & Internet Access:

Would you like to have an email account with us?

 Yes

 No

If yes…

1) I would like my email to be (Choose one, and fill in your email name):

(examples: , or )

2) I would…

a) like my email (above) to directly forward through to this email address:______so I can check it with my existing emails.

b) like to set it up as a stand alone email, which I can either configure my email program to check, or I can log-in to check via the Internet.

3) I would…

a) like to pay by check for my first year fees, of $84.00 ($7/month) my check is enclosed.

b) like to have my first year fees, of $84.00 ($7/month) charged to the credit card below…I understand that the fee for renewal will be charged annually, unless I choose to cancel.

I understand that once my form is processed, I will receive instructions for setting up my email, and accessing the Internet with unlimited dial-up, but that no technical support is provided. (Other than assuring that the account is functioning.) To check for a local access number go to:

Link Form:

Would you like to link with us?

 Yes

 No

If yes…

Step 1)

Paste either this:

Not in (replace this red text with your geographic area)?

Click here for Individual and On-site Group Training Classes Worldwide!

or this:

Not in (replace this red text with your geographic area)?

Click here for Individual and

On-site Group Training Classes Worldwide!

onto your website…You may alter the link in size, as long as it is clear and presentable…you may alter from centered format to left- or right-justified, if it better suits your web page…proceed to step 2…

AFFILIATE EMAIL, INTERNET ACCESS, and LINK FORM

Page 2

Step 2)

List your URL where we can verify that you have pasted our link:

(Note: the link MUST be placed either on your front page, or a logical secondary page, such as a page with information about classes, scheduling, and fees)

List your URL where you would like our websites to link to:

(Note: the link should be to either your front page, or a logical secondary page, such as a page with information about classes, scheduling, and fees)

List your email for our websites to link to (either your existing email, or your new email you have signed up for above):

______(You may still use this option, even if you do not have a website!

Information for link…

Geographic areas you train in:
Do you offer regular Community / Open Enrollment Classes? (Which locations?) /  Yes  No
If you are not using American EHS / American CPR materials in your community/open enrollment classes, which certifying body will you be using?
Training Center Name (If any):
Topics you teach:
Languages:
(Note, although American EHS / American CPR materials are only available in English, Spanish & French, please list any languages in which you are sufficiently fluent to teach classes!)
Telephone Number:

Tell us about yourself… Give us a one paragraph description of yourself and your qualifications and certifications… this is some we use in matching Instructors to clients for training opportunities, and which we may publish when clients want to know who their trainer will be… If you have more than one Instructor affiliated with us, please give us a paragraph on each! (You may fill it in here, or email to with the subject “Instructor Paragraph”:

Example: Instructor Name; Safety Consultant, EMT

13 years Safety / Emergency Medical Services; 7 years Safety and Emergency Response Instructor; Official American Heart Association Instructor; Certified Red Cross Instructor; Certified ASHI Instructor & Instructor Trainer, Sharp Hospital Affiliate Member; Certified Safety Instructor for State of California, County of San Diego; Federal Government Safety Instructor. Licensed Emergency Medical Technician; Certified Operations Level, Hazardous Materials Incident Responder; OSHA Instructor.

Please sign here…by signing, you agree to keep this link actively posted on your website. You further agree that anywhere you mention affiliation with any organization, you also list American EHS / American CPR.

X______Date:______

You may fax your agreement to 760-944-2959

Email Subscribers, please complete page 3 as well

AFFILIATE EMAIL, INTERNET ACCESS, and LINK FORM

Page 3 ~ For Email Subscribers only

If you are paying for Internet Dial-up Access and email, complete the following and sign again:

CREDIT CARD PAYMENT (MC/VISA/AMEX ONLY) / SUBTOTAL
Daytime Tel:
Name on CC:
Expiration Date:
CC #: / TOTAL
Authorized by X______Date______
You may fax your agreement to 760-944-2959 / Send all payments by check to:
Express Compaines, Inc. dba American EHS / American CPR
449 Santa Fe Drive, Suite 127, Encinitas, CA 92024
760.944.1048 E-MAIL: