AED Acquisition Form – Emergency Management & Mission Continuity

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.

Phone

This field is for validation purposes and should be left unchanged.