Please complete each section of this form. Federal Food and Drug Administration (FDA) regulations require a prescription to purchase an automated external defibrillator (AED). If your organization does not have a prescribing physician, check the box marked as such and the EMS Medical Director will send a prescription to your designated AED Coordinator.
*Organization/Company
*Address, Street
*City
*State
*ZIP
*Telephone
*Site Defibrillation Coordinator
*E-Mail Address
*Does your organization have a prescribing physician?		NoYes
*Make & Model of Defibrillator
*Number of Defibrillators
*Location(s) of defibrillator(s)

NOTE: All required items are preceeded with an "*".