Register your AED

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* 1. Name of Organization

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* 2. AED Location Name (If organization is not a corporation, this is the same as the organization name)

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* 3. AED Street Address

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* 4. AED City

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* 5. AED Postal Code

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* 6. AED Location Phone Number

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* 7. Primary Contact Salutation

Dr.

Miss

Mr.

Mrs.

Ms.

Other (please specify)

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* 8. Primary Contact First Name

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* 9. Primary Contact Last Name

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* 10. Primary Contact Email Address

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* 11. Primary Contact Phone Number

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* 12. Organization Website

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* 13. AED Manufacturer

Philips

ZOLL

Cardiac Science

Difibtech

HeartSine

Physio-Control

Welch-Allyn

Other (please specify)

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* 14. AED Model

AED 10

AED 3

AED Plus

HeartStart FR2

HeartStartFRx

HeartStart Onsite

Lifelne

Lifeline View

LIFEPAK 1000

LIKEFPAK CR Plus

LIFEPAK EXPRESS

Powerheart AED G3

Samaritan 300P

Samaritan 350P

Samaritan 500P

Other (please specify)

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* 15. AED Serial Number

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* 16. AED Date Installed (MM/DD/YYYY)

Date / Time

Date

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* 17. AED Placement (please provide specific details on AED location)

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* 18. Battery Expiry Date (MM/DD/YYYY)

Date / Time

Date

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* 19. Pad Expiry Date (MM/DD/YYYY)

Date / Time

Date

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* 20. Please upload a photo of your AED

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File