City of Temple Terrace Customer Service

2. 
3. Temple Terrace Fire Department AED Registration Form
5. Fire Administration
   124 Bullard Pkwy., Temple Terrace, FL 33617 - Phone (813)605-6700, Fax (813) 506-6701
7. AED Registration Program
   The City of Temple Terrace Fire Department identifies the importance of AED's and their use during a cardiac emergency. Completion of this form helps the Temple Terrace Fire Department know where these life-saving units are located. This allows our emergency response personnel to better serve its community by knowing what interventions have been completed prior to their arrival and ensuring the highest level of patient care.
9. Contact information:
11. Organization / Business Name*
13. First Name*
14. Last Name*
16. Street Number*
17. Street Name*
18. Street Type*
19. Apt #
21. City*
22. State
23. Zip*
25. Cellular Telephone*
26. Home Telephone
27. Business or Work Telephone
29. Email address:
31. AED information:
33. Date of installation:*
    Date of installation:
34. AED Manufacture:*
35. AED Model:*
37. AED installation location:*
    Please be specific on installation locations (i.e., West wall of gym, patient waiting room, principal's office, etc.)
39. Is AED in a monitored cabinet?*

    1. Yes
    2. No
40. Has staff been trained in AED use?*

    1. Yes
    2. No
41. Has staff been trained in CPR?*

    1. Yes
    2. No
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field