Material Purchase Request Form

Personal Information
*Fields marked with are required**
*Name:
*Address:
*City:	*State:	*Zip Code:
*Phone:	*E-mail:
Orginization Information
*School / Organization Name:
*Address:
*City:	*State:	*Zip Code:
Method of Payment:
.
Through the non-profit CPR Safe program we are happy to help schools obtain CPR and AED training materials at a great discount that we pass on to you. This form can be used to request commonly purchased materials. Prices below are catalog prices as of Spring 2009 and do not include any discounts or shipping costs. If you need other items not listed here or have any questions, please fill in the “Notes” section below and submit your request for assistance.
Heartsaver AED books @ $12.00 each	Quantity:	Cost:
Heartsaver First Aid books @ $8.50 each	Quantity:	Cost:
Heartsaver First Aid books (with CPR & AED) @ $13.95 each	Quantity:	Cost:
Heartsaver Pediatric First Aid books (with CPR & AED) @ $13.95 each	Quantity:	Cost:
BLS Healthcare Provider books @ $11.00 each	Quantity:	Cost:
Heartsaver AED DVD @ $75.00 each	Quantity:	Cost:
Heartsaver First Aid DVD @ $90.00 each	Quantity:	Cost:
BLS Healthcare Provider DVD @ $65.00 each	Quantity:	Cost:
CPR Reminder cards- Infant/Child CPR packs of 100 @ $10.00 each	Quantity:	Cost:
CPR Reminder cards- Adult CPR/AED & Heart attack/Stroke packs of 100 @ $10.00 each	Quantity:	Cost:
First Aid Quick Reference Guide @ $5.00 each	Quantity:	Cost:
CPR Practi-Shield Training Face Shield boxes of 50 @ $11.25 each	Quantity:	Cost:
AED Trainer (prices vary-we will contact you with various options)	Quantity:
AED Unit (prices vary-we will contact you with various options)	Quantity:
Manikins (prices vary-we will contact you with various options)	Quantity:

	Total Number of Items:	Total Cost $:
If you wish to purchase AED trainers, AED units or manikins, please provide any additional information about your needs in the “Notes” section below. We will contact you to discuss options.
Notes:
After submitting your purchase request you will receive an e-mail confirmation that will include shipping information/costs, as well as any available discounts. Your order is NOT FINAL until you reply to this confirmation e-mail. Please allow a minimum of 2 weeks for receipt of materials from the receipt of your confirmation e-mail.
Please make sure that any field marked with * is filled in before submitting

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Material Purchase Request Form