ACLS Registration - Register in 3 easy steps

1. Select the date that you would like to attend and complete the form below. 2. Print this page, enclose payment to "NIEC" and any prerequisites listed on course description page.
3. Mail form, payment and
 prerequisites to:
     P.O. BOX 11176
     Philadelphia, PA 19136
FULL ACLS COURSE  $280.00 with textbook - $230.00 without text book. 
Please select a date:

RECERTIFICATION ACLS COURSE  $240.00 with textbook - $190.00 without text book.

Please select a date:



City: State:   Zip:

Phone (Day):   Evening:

Select one:  Physician  Nurse   Paramedic   Other:

**Cancellations if submitted at least 2 weeks prior to course will be accepted less $50.00 administrative fee.
+ Send copy of current ACLS card if registering for re-certification course.