Log Safe On-Line Registration

Pre-Registration is Required.  Please call Deb Jacobson at 218-749-7731 or email deb.jacobson@advancedmn.org with any questions about this online form.

OSHA Class is 4 hours in AM only.

CPR includes First Aid and is 8 hours all day.

First Name (required)

Middle Initial (required)

Last Name (required)

Last 4 of SSN (optional)

Student Primary Phone Number (required)

Alternate Phone Number

Mailing Address (required)

City (required)

State (required)

Zip Code (required)

Student Email

Please check which class(es) you would like to attend

OSHA Class is AM Only

SPRING COURSES
CPR - March 23 Rochester - Canadian Honker/Apache
CPR - March 30 International Falls - American Inn
OSHA - March 30 International Falls - American Inn
CPR - March 31 Baudette - Sportsman Lodge
OSHA - March 31 Baudette - Sportsman Lodge
CPR - April 1 Brainerd - Central Lakes College
OSHA - April 1 Brainerd - Central Lakes College
OSHA - April 7 Two Harbors - Community Center
CPR - April 8 Two Harbors - Community Center
CPR - April 13 Cloquet - Forestry Center
OSHA - April 13 Cloquet - Forestry Center
OSHA - April 15 Tower - Fortune Bay
CPR - April 15 Tower - Fortune Bay
CPR - April 20 Hibbing Community College
OSHA - April 20 Hibbing Community College
OSHA - April 22 Bemidji - Sanford Center
CPR - April 22 Bemidji - Sanford Center
CPR - April 27 Grand Rapids - Itasca College
OSHA - April 27 Grand Rapids - Itasca College
OSHA - April 28 Northome - Gratten Town Hall
CPR - April 29 Northome - Gratten Town Hall

FALL COURSES
CPR - Oct. 13 International Falls - American Inn
OSHA - Oct. 13 International Falls - American Inn
CPR - Oct. 14 Bemidji - Holiday Inn
OSHA - Oct. 14 Bemidji - Holiday Inn
CPR - Oct. 20 Cloquet - Forestry Center
OSHA - Oct. 20 Cloquet - Forestry Center
CPR - Oct. 21 Hibbing Community College
OSHA - Oct. 21 Hibbing Community College
CPR - Dec. 8 Hibbing Community College
OSHA - Dec. 8 Hibbing Community College

PAYMENT METHOD

Please check all that apply
Check - Payable to Advanced Minnesota
Credit Card - Please call with Credit Card information
Purchase Order or Letter of Billing Authorization

Please fax: 218-749-7782
or mail to: Advanced Minnesota
1001 West Chestnut Street
Virginia, MN 55792

THIRD PARTY BILLING INFORMATION

If you are paying via Purchase Order or Letter of Billing Authorization, please enter the third-party billing information below.

Billing Contact Name

Billing Mailing Address

City

State

Zip Code

Billing Contact Phone Number

NHED NHED NHED NHED NHED