SOLO WILDERNESS MEDICINE
LOST/REPLACEMENT CARD APPLICATION
HELP! I lost my card!
Don’t worry—we can fix that. If a SOLO certification card is lost or damaged, we will replace it for $10. You
may pay by cash, check, money order, or credit card. All information MUST be provided below. If you are
unsure of course dates or other valid information, SOLO will charge $25 to research certification history.
SOLO also reserves the right to deny a replacement card if proper information is not provided. If you are
unsure about dates and locations, we recommend checking bank statements or credit card records as a
reference.
You may mail, email, or fax this form to SOLO. Please allow 2-4 weeks to receive your new card. Telephone or
rush orders will cost $25.00.
Please circle type of certification card(s) that you need: WEMT WFR WFA CPR
To get a new card, please give us the following information (in writing):
SECTION I: BACKGROUND INFORMATION
FULL NAME __________________________________________
STREET ADDRESS _____________________________________
CITY _______________________________ STATE __________ ZIP __________
DAYTIME PHONE _____________________ EVENING PHONE ____________________
E-MAIL ADDRESS _____________________________________
SECTION II: SOLO CERTIFICATION HISTORY
TYPE OF CERTIFICATION (WFA, WFR, WEMT, etc.) ________________________
DATES OF COURSE __________________________________________________
LOCATION OF COURSE _______________________________________________
NAME OF COURSE INSTRUCTORS ______________________________________
SECTION III: RECERTIFICATION INFORMATION: (Only for students who have recertified)
ORIGINAL COURSE TAKEN WITH? (Circle One) SOLO WMI WMA Other __________________
DATE AND LOCATION OF ORIGINAL COURSE _________________________________
DATE AND LOCATION OF LAST RECERTIFICATION _____________________________
NAME OF COURSE INSTRUCTORS __________________________________________
SECTION IV: CPR HISTORY (ONLY REQUIRED FOR WFR & WEMT CERTIFICATIONS)
DATE OF LAST VALID CPR COURSE* _______________________________________
SECTION V: PAYMENT
TYPE OF PAYMENT: CHECK MONEY ORDER CASH CREDIT CARD (Visa/MasterCard/Discover)
FOR CREDIT CARD PAYMENTS ONLY: VISA MASTERCARD DISCOVER
CREDIT CARD # EXP DATE CVV#
BILLING ADDRESS ___________________________
CITY STATE ZIP
PAYMENT TOTAL: (Check one)
$10.00 (REPLACEMENT FEE per CARD)
$25.00 (FOR INCOMPLETE FORMS NEEDING CERTIFICATION RESEARCH)
$25.00 (FOR RUSH ORDERS)
TOTAL $________
Mail, Email, or Fax this application and replacement fee to:
SOLO - c/o Card Replacement
PO Box 3150, Conway, NH 03818
FAX: (603) 447-2310
EMAIL: [email protected]
Your new card will be mailed directly from SOLO once all paperwork is complete and approved by the
certification coordinator.
FOR OFFICE USE ONLY
Paid (cc, check #____________________)
Roster
Card sent (date: _____________________)
Data base
