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:
Street or Box Number
City State Zip
Phone Number with Extention
AED Custodian Contact Information:
Hours of Operation
Custodian Name
Street or Box Number
City State Zip
Phone Number E-mail Address
AED Equipment Information:
Date AED was Installed Drop-down List
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
Street or Box Number
City State Zip
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 contact our PAD Coordinator at 904-209-1733 or to find training that meets
your needs..
Please Submit by fax (904)209-1783 or by e-mail
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 contacting you of the location of your AED...