INSTRUCTOR AGREEMENT             I have obtained the required current EFR Instructor materials and have made myself familiar with the contents. I understand I 

cannot conduct any Emergency First Response (EFR) courses until I receive authorization from EFR. I further agree that when conducting EFR courses I will abide by all 

EFR Standards and procedures as published and updated by EFR. I will maintain familiarity with EFR educational materials, including revisions to existing materials and 

the introduction of new materials. I affirm that I have read and will abide with the EFR License Agreement found in the Appendix Section of the EFR Instructor Guide. I 

understand and agree that any criminal conviction on my part involving abuse of a minor or sexual abuse of an adult, occurring either during or prior to my certification 

as an EFR Instructor, will be automatic grounds for denial or revocation of my credential. I also understand EFR may refuse to accept my application or rescind any EFR 

Instructor credentials I may have if EFR determines my certification is not in the best interest of Emergency First Response.  

 

Applicant Signature _______________________________________________________________   Date Signed  ________________________ 

                                                                                                                                                                                                       D/M/Y 

CERTIFICATION INFORMATION (To be completed by the Emergency First Response Instructor Trainer.)
Course Location _______________________________________________________________________________________________________________________

 

City 

State or Province 

Country

Date Course Completed ___________________________  If applicable: Facility Name  _______________________________________ No. _________________________
                                                                      

D/M/Y

Instructor Trainer Name __________________________________________________________________ Instructor No. ____________________________________

 

(Please Print)

Instructor Trainer Signature _______________________________________________________________ Date Signed  ____________________________________
 

D/M/Y

COURSE INFORMATION AND PREREQUISITES (To be completed and initialed by Emergency First Response Instructor Trainer)
M

 Instructor Course 

_____  Current EFR Primary/Secondary Care;    or    _____ Medical Professional

M

 Instructor Crossover 

_____  Current CPR/First Aid Instructor

M

 Retraining Course 

_____  Emergency First Response Instructor

Product No. 10245  (Rev. 02/12)  Version 2.10 

© Emergency First Response Corp. 2012

® indicates a trademark is registered in the U.S. and certain other countries.

Emergency First Response® 

Instructor Application

PLEASE PRINT CLEARLY       Check here if this is a change of address and you want our records changed accordingly.

Name _____________________________________________________________________________________________  M PADI Member No. _________________

 

First 

Initial 

 Last

Mailing Address _____________________________________________________________________________________  M Non-PADI Member ________________

City _______________________________________________________________________  State/Province  _____________________________________________

Country  ________________________________________________________________  Zip/Postal Code ___________________________________________ 

Home Phone  (_____)________________________________________________________  Business Phone (_____)______________________________________

FAX  (_____)________________________________________________________________  Email _____________________________________________________

Date of Birth ___________________________      Sex:     M 

 F 

Preferred Language  _________________________________________

___

 D/M/Y 

CHECKLIST

   Application completed in full
   Applicant and Trainer signatures
   Copy of certifications (for crossovers only)
   See price list for fee

MAIL TO – Your Emergency First Response Regional Headquarters
Visit emergencyfirstresponse.com for Regional Headquarters 

locations.

Rec’d ____________ Entr’d ____________ Shp’d __________

PAYMENT METHOD

See current price list for payment information.

 

 MasterCard 

 

VISA 

 

American Express

  

Discover Card 

 

JCB 

 

Maestro (UK only)

  

Check/Bank Draft No.* ______________________________________

* Check/Bank  Draft  must be payable in the currency of the PADI Regional 

Headquarters the application is submitted to.

Card Number  _________   __________   __________  __________
Card expiration date ___________________________________________  
Maestro (UK only)
Cardholder Name ______________________________________________

  

  

Please Print

Authorized Signature  __________________________________________