Application for AED Program


Click here to view/print a paper form that you can mail/fax to SVMCA.



Type of application: 

Date: 


Organization Information
Name of organization/AED owner:  
Manager/director/administrator of above organization:  
Title:  
Organization's mailing address:  
Phone #:  
Fax #:  


AED Information
Name of AED site:  
Site Address:
(Physical address, not mailing address)
 
AED program coordinator:  
Specific location of AED within site:
(Please be as specific as possible)
 
Brand of AED/serial #:  
   
Expiration dates:  
Battery Pads Adult
Pediatric
Is AED a replacement?:  
If yes, list brand and serial # for old unit:


Program Type:  (check all that apply)
Private corporation - Profit Airport Construction site
Non-profit - Private Store - Open to public Stadium/sports/gathering place
Government agency Business/office complex School/college
Industrial complex Other:


Training:  (check all that apply)
AHA HeartSaver AED American Red Cross National Safety Council
# trained personnel:  Additional projected (if any) 
Will the general public (people not affiliated with the AED program) have access to use the AED?