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4. Current Certications, Qualications and Licenses (To be completed for all applicants)
Applicant is currently certied, qualied, or licensed at the following level. Check all that apply.
3 BLS and Advanced Emergency
Medical Technician
3 BLS and Advanced First Aid
3 BLS and Certied Athletic Trainer*
3 BLS and Emergency Medical
Responder
3 BLS and Emergency Medical
Technician
3 BLS and First Aid
3 BLS and Licensed Practical Nurse
3 BLS, ACLS, and Physician Assistant
3 BLS and Registered Nurse
3 BLS and Wilderness Emergency
Medical Technician
3 BLS and Wilderness First Responder
3 BLS Only
3 BLS, ACLS, and Advanced Practice
Registered Nurse
3 BLS, ACLS, and
Certied Emergency Nurse
3 BLS, ACLS, and Medical Doctor
3 BLS, ACLS, and Paramedic
3 BLS, ACLS, and Registered Nurse
3 BLS, ACLS, and
Respiratory Therapist
3 CPR/AED Only
3 Adult 3 Pediatric 3 Both
3 First Aid Only
3 First Aid/CPR/AED
3 Adult 3 Pediatric 3 Both
* Bachelor/Master’s degree from professional athletic training education program and pass test administered by Board of Certication
5. Applicant Agreement and Attesting Statements (To be completed by applicant)
Have you ever had a government license, permit, or professional certication suspended, revoked, or 3 Yes 3 No
denied, pled no contest, or been convicted of a felony? If yes, please provide a detailed explanation.
Such circumstances do not absolutely preclude approval but are subject to the review and decision of the
HSI Quality Assurance Board.
I agree to comply with the terms and conditions of Instructor or Instructor Trainer Authorization as 3 Yes 3 No
described in the most current version of the Training Center Administrative Manual, Standards and Guidelines
For Quality Assurance.
Please send news and promotional information via emails
3 Yes 3 No
Applicant Name (Please Print) ____________________________________________________________________________________________
Signature of Applicant ____________________________________________________________ Date ______________________________
6. Training Center Afliation and Agreement (To be completed by Training Center Director)
I am the Training Center Director responsible for managing the Training Center. I agree to comply with the terms and conditions
of Training Center Approval as described in the most current version of the Training Center Administrative Manual, Standards and
Guidelines for Quality Assurance, which includes keeping this application and current credentials on le.
Training Center (TC) Name ________________________________________________________ TC ID _____________________________
TC Director Name (Please Print) ______________________________________________________
Signature of TC Director ___________________________________________________________ Date ______________________________
7. Payment
3 Check or Money Order | Check Number __________________________________ 3 P.O. ___________________________________
(If submitting Check, Money Order or PO, call Client Services at 800-447-3177 to determine full amount including tax.)
3 Credit card (Training Center will be contacted for payment information by Registry at time of processing.)
Point of Contact __________________________________________________________________ Telephone _________________________
To access your instructor’s Digital Authorization Card in Otis go to:
Organization>Instructors>Manage Instructors from the navigation bar. Either search for your Instructor by name or click View All. To
the right of the Instructor’s name click Actions and you will nd the link to the Digital Instructor Authorization Card.
Application Processing
Training Center Directors: Enter information from this form into the Online Instructor Application found in Otis.
New Instructor applicant establishing a new Training Center: Use information from this form when completing the online Training
Center eApplication at hsi.com/becomeaninstructor
Authorization period and fees: Authorization Period is two years. Authorization fee when submitted via online application: $20 plus
tax where applicable. When submitted via mail, email, or fax: $40 plus tax where applicable; contact client services at 800-447-3177
for details. Allow 7–10 business days for processing.
IMPORTANT NOTE
Copies of this application, and all associated credentials or
Instructor Development Course completion documentation must be
kept on file for the length of the affiliation with the Training Center.
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