ASHI Instructor Application

Candidate Information

Last Name *

First Name *

Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Email *

Phone *

Instructor Qualifications

Instructor Credentials

Applicant has the following current and valid Instructor Trainer credentials (check all that apply)Authorized Instructor TrainerAAP InstructorAcademic Degree in EducationAcademic Degree in MedicineAHA InstructorARC InstructorASHI InstructorCertified Emergency Nurses Association InstructorCertified EMS InstructorCertified Fire InstructorCertified Law Enforcement InstructorCertified Mine Safety and Health Administration InstructorCertified National Traffic Safety Institute InstructorCertified Scuba Diving InstructorCertified/Licensed School TeacherDAN InstructorECSI/AAOS InstructorEFR InstructorEMSSS InstructorILTP InstructorMedic/First Aid InstructorMilitary Training InstructorNOLS/WMI InstructorNSC InstructorNSP InstructorOSHA Authorized TrainerSAI InstructorSOLO InstructorWMA InstructorYMCA InstructorOther Teaching Credential (Submit)

Attach Copy of Current Credentials

Current Certifications / Licenses

Applicant is currently certified, qualified or licensed at the following level (check all that apply)BLS (Basic Life Support)Advanced EMTAdvanced First AidCertified Athletic TrainerEMREMTBasic First AidLPNACLSRegistered NurseWilderness EMTWilderness First ResponderAdvanced Practice RNCertified Emergency NurseMedical Doctor (MD)ParamedicRespiratory TherapistCPR/AED

Online Application

Candidate Information

Applicant Agreement and Attesting Statements

Verification