AED registration form

AED customer information

Mailing address:

Check if this is a private residence.

Business phone with area code:

Site Coordinator information

Phone number with area code:

Alternative phone number with area code:

AED information

This is a new AED registration
This is an update or revision to a currently registered AED

Street address of AED location:

Common name of building/office/location

Placement of AED: Describe the location of the device at this address:

Is the AED accessible to the public?
Yes No

Check if you do not want your registered AED listed in the Pulse Point app.

What are the days of the week that the AED is accessible at the site?

What are the hours that the AED is accessible at the site?

Is the AED available 24/7?

Yes No

Are additional items placed with the AED?

Check if a Bleeding Control Kit is present.

Check if a Naloxone is present.

Check if a Epinephrine is present.

Optional AED information

Expiration date of AED battery:

Expiration date of AED electrodes:

Additional comments or instructions:

How did you hear about AED registration requirements?

This website

Traditional media (television, radio, newspaper)

Social media (Facebook, Twitter, YouTube, etc.)

Online search (Google, Bing, Yahoo, etc.)

Word-of-mouth (heard from someone else)

CPR/AED training

AED manufacturer/distributor

Presentation

PulsePoint mobile app

AED program management company

Submit Registration