TRAUMA NURSING CORE COURSE APPLICATION
Circle one
PROVIDER- 7th Ed _____
INSTRUCTOR – 7th Ed _____
PLEASE NOTE: We recommend that you use eCourseOps to register courses: www.ena.org/Education/eCourseOps
Send Paper applications at least 8 weeks prior to the course via Fax: 847-460-4001 or Email: courseops@ena.org
If you are sending payment for indirect fees or manuals, please mail to ENA Coursework, PO Box 1276, Bedford Park, IL
60499-1276
If applications are received less than 3 weeks before the course, ENA will assess a $200 Late Fee plus shipping
costs if express shipping is needed for scantrons and certificates. The following information is required for course
authorization from ENA.
COURSE INFORMATION
Number of Expected Participants: ___________
Date(s) of Course (one application per course):________________________________________________
Facility Name: _________________________________________________________________________
Street Address: _________________________________________________________________________
City, State/Province, Postal Code:___________________________________________________________
Country:_______________________________________________________________________________
Contact Name for ENA Web site: ___________________________________________________________
Contact Phone # and/or Email Address for ENA Web site: _______________________________________
COURSE DIRECTOR DATA (if Course Director to be billed please supply billing address)
Name: __________________________________________________________________________________
Address: ________________________________________________________________________________
City, State/Province, Postal Code:_____________________________________________________________
ENA Membership/Instructor #:_______________ Last 4 Digits of Social Security/Insurance #____________
Work Phone Number: ______________________________________________________________________
Home Phone Number:
____________________________________________________________________
E-mail Address: ___________________________________________________________________________
If you are mentoring an instructor in this course to become a Course Director, please provide their
name and instructor number:
_______________________________________________________
Name of Instructor to be Mentored as a Course Director
_______________________
Instructor Number
Please refer to one of the following locations on the ENA website to make sure that the instructors you
are using will have a current TNCC 7th Edition instructor status at the time of your course:


Course Director Only/Course Reports/Current Instructors Report
eCourseOps/Access eCourseOps/Reports/ Current Instructors Report
TRAUMA NURSING CORE COURSE (TNCC) APPLICATION – PAGE 2
BILLING DATA – If other than Course Director to receive invoices, please note below.
Name: ______________________________________________________________________________
Institution and Department (if work address): _______________________________________________
Address:____________________________________________________________________________
City, State/Province, Postal Code: ________________________________________________________
Contact Phone Number: ________________________E-mail: _________________________________
PLEASE SEND COURSE SCANTRONS AND CERTIFICATES TO:
Name:
_____________________________________________________________________________
Institution and Department: (if work address) ________________________________________________
Address:______________________________________________________________________________
City, State/Province, Postal Code:__________________________________________________________
Country:______________________________________________________________________________
PLEASE SEND MANUALS TO: ***No P.O. Boxes Please***
Name:_________________________________________________________________________________
Institution and Department: (if work address) __________________________________________________
Address: _______________________________________________________________________________
City, State/Province, Postal Code:____________________________________________________________
Country:________________________________________________________________________________
Number of Provider Manuals: 7th edition @ $68 ea______
Number of Instructor Supplements: 7th edition @$50 ea ______ (printed; member price)
(7th edition printed Instructor Supplements are $80 if sold individually to non-member ENA instructors)
Number of Downloadable Instructor Supplements: @ $30 ea_____(member price)
($60 if sold individually to non-member instructors)
I have enclosed a check/money order payable to: Emergency Nurses Association in the amount of
$__________ for Books, $__________ for Indirect Fees, $__________for Late Fee
I have listed my credit card information. Please process a total charge in the amount of $_________
$__________for Books, $__________ for Indirect Fees, $___________for Late Fee
Card Number: ___________________________________ Expiration Date: __________________
Name on Card: ___________________________________________________________________
Credit Card Billing Address: _________________________________________________________
Contact Name: ______________________________ Contact Phone Number: _________________
MANUALS MUST BE PAID IN ADVANCE; WE DO NOT ACCEPT PURCHASE ORDERS
Check here if needed: Receipt ______ Invoice for indirect fees______ Invoice for manuals______