Hosted E-Learning Site License Order Form

Please use this form for institutional access only. We will respond to your request within five (5) business days. Providing inaccurate or incomplete information may delay or stop the processing of your order.

If you are ordering for yourself, please refer to the individual courses and pricing.

Your Information

*Your Email Address:

*Your First Name:

*Your Last Name:

*How did you hear about us?

*Do you currently have a Learning Management System? Yes
No

*Type of Facility:

*Number of Beds:

*Area employed:

*Primary position:

Site License

What site license term are you interested in?

One year
Two years
Three years

End-User Licenses

Please enter the number of end-user licenses you wish to purchase. New customers: Please select a minimum of three (3) end-user licenses. Licenses do not need to be for the same course.

Essentials of Critical Care Orientation

Basic ECG Interpretation

Essentials of Nurse Manager Orientation

The Preceptor Challenge: The AACN Preceptor Development Program

Promoting Excellence in Palliative and End-of-Life Care

Essentials of Pediatric Critical Care Orientation

AACN: Critical Care Pharmacology

Organization Information

Please enter the legal facility name and address to be included on the site license service agreement.

*Organization's Complete Name:

*Country:

*Address:

Address 2:

*City:

*State:

*Zip/Postal Code:

*Will this facility have active learners?: Yes
No

Additional Site Manager Accounts

Each site license comes with three (3) full content manager accounts. Do you need additional accounts?

Number of additional accounts:

Point of Contact (POC) for Site Administration, Contracting and Invoicing

*POC First Name:

*POC Last Name:

*POC Title:

*POC Email Address:

*POC Phone Number: -- ext.

Additional Facilities

Do you have other facilities you would like added to this contract? Yes

Legal Name:

Country:

Address:

City:

State:

Zip:

Add to Facilities List

Legal Name	Address	City	State	Zip	Country	CountryCode
							Remove

Payment Options

We accept checks, credit cards and EFTs.

Credit cards:: Please complete the information at the bottom of the E-Learning invoice and fax to 949-448-5521.
EFT:: Please advise us so we are aware of the incoming wire.

Purchase order: This is for your reference only. AACN does not accept PO's as payment.

Your Purchase Order # for this order: