CENTRAL INDIA RESUSCITATION INSTITUTE                       

Candidate Registration Form

    Course name

    Name

    Qualifications

     Place of work

    Designation at work

    Postal Address

    Email id

    What do I want from this course?

    How did you know about CIRI?

    Any special requirement?

   (Please note that the course may need candidate kneeling down on the floor for    performing CPR. Any candidate with any knee problems should mention it in the above space.)

    Signature of the candidate                                            Date:  

Please note the following:

1) Without paying the full course fees the place is not guarenteed.

2) It is mandatory that candidate attends the full course.

3) It is expected that candidate has read the course materials before attending the course.

4) Please print this form and give it to the course organisers at the time of payment of the course fees.