AED Registration Form

To register your AED with local emergency service agencies, please fill out the following form.

Name of the organization or individual that owns the AED:

The physician who prescribed the AED, if any:

Physician's Name:
Street or Box Number:
City:
State:
Zip Code;
Phone:	( )- ext. (if no extension, leave blank)

AED Coordinator/Owner's Contact Information:

Coordinator's Name:
Street or Box Number:
City:
State:
Zip Code:
Phone:	( )- ext. (if no extension, leave blank)
E-mail:

AED Equipment Information:

Date AED was installed:	(MM/DD/YY)
AED Manufacturer:
AED Model Number:
AED Serial Number:

Where is the AED Located?

*Please note: Local EMS agencies will be notified of your AED registration based on the address information entered below. Please be sure and put the address where the AED is physically located rather than your corporate headquarters or other address.

Street Address:
City:
State:
Zip Code:
Where is the AED located at the address? Be as specific as possible.

What is your CPR/AED training status?

If you selected "I/We need training," please go to our CPR/AED class schedule to find training that meets your needs.

Upon submission, you will receive a confirmation copy of the information you submitted, which may be printed for your records. Your entry will be added to the AED Registry database, and your local emergency service agency/agencies will be notified of the location of your AED.