APPLICATION FORM

Applicant Contact Name

First name:

Last name:

Applicant Position (Admin, CEO, etc):

Email:

Fax:

Phone:

Street Address:

Apt / Suite:

City:

State:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code:[postcode* zip]

Proposed # of AEDS:

Preferred AED Brand:—Please choose an option—Philips HeartStartCardiac ScienceZollHeartsinePhysio

Estimate the total # of people in your immediate city/town/village/township:

< 499500-9991000-29993000-5000> 5000

% Adult:

% Children under 8 years old:

Does your agency/institution currently own an Automated External Defibrillator:

CPR/AED training is mandatory to be eligible for this grant. Discounted training will be added to the cost unless proof of current CPR/AED certification is provided.

Submitting this application in no way obligates me to participate.