AED test sheet - Lifesaving Society

1
2
Result
Y/M/D
Sex M
1
One and Two Rescuer AED
Side 1: Please print each candidate's name and contact information legibly.
AED Knowledge: use and operation
CPR prerequisite checked
Date of Birth
Lifesaving AED
F
Name
Address
Postal code
City
E-mail
Telephone
Sex M
2
F
Name
Address
Postal code
City
Telephone
E-mail
Sex M
3
F
Name
Address
Postal code
City
E-mail
Telephone
Sex M
4
F
Name
Address
Postal code
City
E-mail
Telephone
Sex M
5
F
Name
Address
Postal code
City
E-mail
Telephone
Sex M
6
F
Name
Address
Postal code
City
E-mail
Telephone
Check box if there are more candidates on the reverse side of this page.
This test sheet is page ___ of ___ pages.
9 Satisfactory Performance
Instructor Information
F Fail
Total Pass for Course
Total Fail for Course
Exam Information
Exam Date:
Instructor's Name
E-mail
(
)
MM
DD
Facility name
Telephone
Exam fees attached
(
)
Telephone
Awards information
Signature
Payment Information
Awards issued by affiliate
Awards not issued
Exam fees not attached
Examiner Information
Send invoice or receipt to
(
Affiliate
)
Telephone
Examiner's Name
ID#
E-mail
Address
City
YY
ID#
Province
Postal Code
(
)
Telephone
Return completed test sheet to the Lifesaving Society Branch Office promptly after the exam. Retain one copy for your records. Do not send cash by mail.
Signature
1
2
Result
Y/M/D
Sex M
7
One and Two Rescuer AED
Side 2: Please print each candidate's name and contact information legibly.
AED Knowledge: use and operation
CPR prerequisite checked
Date of Birth
Lifesaving AED
F
Name
Address
Postal code
City
E-mail
Telephone
Sex M
8
F
Name
Address
Postal code
City
E-mail
Telephone
Sex M
9
F
Name
Address
Postal code
City
E-mail
Telephone
Sex M
10
F
Name
Address
Postal code
City
E-mail
Telephone
Sex M
11
F
Name
Address
Postal code
City
E-mail
Telephone
Sex M
12
F
Name
Address
Postal code
City
E-mail
Telephone
Check box if there are more candidates on the reverse side of this page.
This test sheet is page ___ of ___ pages.
9 Satisfactory Performance
F Fail
Total Pass for Course
Total Fail for Course
Exam Information
Exam Date:
YY
(
Affiliation
MM
DD
)
Telephone
Facility name
Please complete Instructor, Awards and Payment information sections on Side 1 of test sheet. Host name, Exam information, and
Examiner sections must be completed on both sides 1 and 2 of the test sheet.
Veuillez s'il vous plaît remplir les informations pertinentes dans les sections concernant les moniteurs, les certificats et le mode de
paiement au recto de la feuille. Il faut inscrire les renseignements concernant l'examen et l'évaluateur sur les deux côtés de la
feuille d'examen.
(
)
Telephone
Awards information
Awards issued by affiliate
Awards not issued
Examiner Information
Examiner's Name
ID#
E-mail
(
)
Telephone
Return completed test sheet to the Lifesaving Society Branch Office promptly after the exam. Retain one copy for your records. Do not send cash by mail.
Signature