AED Acquisition Form – Emergency Management & Mission Continuity

To be completed prior to buying an AED

Complete this form prior to purchasing an AED
AED Owner*
First Last
Contact Phone Number
Monthly Inspector Name*
This person will be responsible for the monthly checks of the AED.
First Last
Email*
Alternate Monthly Inspector Name*
This person will be responsible for the monthly checks of the AED.
First Last
Alternate Email*
Department Head of Requester*
Building Name*
How Many Requested*
Desired Location(s)*
Where would you like to store / mount the AED(s)
Trained Personel*
Pursuant to state contract pricing a minimum of 5 people must be trained to use the AED. List those people here.
Name
This field is for validation purposes and should be left unchanged.