N
ORTH GEORGIA TECHNICAL COLLEGE | PO BOX 65 CLARKESVILLE, GA 30523 | CONTED@NORTHGATECH.EDU
Instructor Agreement Affiliation with
North Georgia Tech TC
First and Last Name:
(please print)
Address:
City: State: Zip:
Cell Phone: Work Phone:
Email Address:
Employer:
Please mark the appropriate disciplines for which you are requesting to become an Instructor in:
BLS
ACLS
PALS
Please include a copy of all current provider cards.
I, , do hereby agree to follow the requirements of AHA and
NGTC in teaching any and all courses affiliated with AHA. This includes using the appropriate
instructor tool kit, providing AHA manuals before, during and after classes to students, and
providing cards after the course is completed; as well as submitting the roster to the TC for
teaching credit. I realize I must teach 4 courses and be monitored in a two-year period and attend
an update in all disciplines I am an instructor in to maintain my current instructor status.
Signature: Date:
CTC Rep: Date:
Submit to: Leslie Foster
conted@northgatech.edu
North Georgia Technical College
AHA Training Center
PO Box 65
Clarkesville, GA 30523
706-754-7715
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signature
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