AED test sheet - Lifesaving Society
AED test sheet - Lifesaving Society
AED test sheet - Lifesaving Society
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1<strong>Lifesaving</strong> <strong>AED</strong>Side 1: Please print each candidate's name and contact information legibly.Sex M FDate of BirthY/M/DCPR prerequisite checked<strong>AED</strong> Knowledge: use and operationOne and Two Rescuer <strong>AED</strong>1 2ResultNameAddressCityPostal codeE-mail2TelephoneSex M FNameAddressCityPostal codeE-mail3TelephoneSex M FNameAddressCityPostal codeE-mail4TelephoneSex M FNameAddressCityPostal codeE-mail5TelephoneSex M FNameAddressCityPostal codeE-mail6TelephoneSex M FNameAddressCityPostal codeE-mailCheck box if there are more candidates on the reverse side of this page.This <strong>test</strong> <strong>sheet</strong> is page ___ of ___ pages.Instructor InformationInstructor's NameID#Telephone Satisfactory PerformanceExam InformationExam Date:F FailYY MM DDTotal Pass for CourseTotal Fail for CourseE-mail( )Telephone SignaturePayment InformationExam fees attachedSend invoice or receipt toExam fees not attachedFacility nameAwards informationAwards issued by affiliateAwards not issuedExaminer Information( )Affiliate Telephone Examiner's NameID#( )TelephoneAddressE-mail( )City Province Postal CodeTelephoneReturn completed <strong>test</strong> <strong>sheet</strong> to the <strong>Lifesaving</strong> <strong>Society</strong> Branch Office promptly after the exam. Retain one copy for your records. Do not send cash by mail.Signature
7<strong>Lifesaving</strong> <strong>AED</strong>Side 2: Please print each candidate's name and contact information legibly.Sex M FDate of BirthY/M/DCPR prerequisite checked<strong>AED</strong> Knowledge: use and operationOne and Two Rescuer <strong>AED</strong>1 2ResultNameAddressCityPostal codeE-mail8TelephoneSex M FNameAddressCityPostal codeE-mail9TelephoneSex M FNameAddressCityPostal codeE-mail10TelephoneSex M FNameAddressCityPostal codeE-mail11TelephoneSex M FNameAddressCityPostal codeE-mail12TelephoneSex M FNameAddressCityPostal codeE-mailCheck box if there are more candidates on the reverse side of this page.This <strong>test</strong> <strong>sheet</strong> is page ___ of ___ pages.( )Affiliation TelephonePlease complete Instructor, Awards and Payment information sections on Side 1 of <strong>test</strong> <strong>sheet</strong>. Host name, Exam information, andExaminer sections must be completed on both sides 1 and 2 of the <strong>test</strong> <strong>sheet</strong>.Veuillez s'il vous plaît remplir les informations pertinentes dans les sections concernant les moniteurs, les certificats et le mode depaiement au recto de la feuille. Il faut inscrire les renseignements concernant l'examen et l'évaluateur sur les deux côtés de lafeuille d'examen.Telephone Satisfactory PerformanceExam InformationExam Date:Facility nameAwards informationAwards issued by affiliateAwards not issuedExaminer InformationExaminer's NameF FailYY MM DDTotal Pass for CourseTotal Fail for Course( )TelephoneID#E-mail( )TelephoneReturn completed <strong>test</strong> <strong>sheet</strong> to the <strong>Lifesaving</strong> <strong>Society</strong> Branch Office promptly after the exam. Retain one copy for your records. Do not send cash by mail.Signature
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