TOP Program Individual Request
Use this form is you are an individual applying for the TOP program
Title/Rank *
Your answer
First Name *
Your answer
Last Name *
Your answer
Your agency name. Please type complete name. *
Your answer
Email *
Your answer
Phone Number *
Your answer
Do you already possess a tourniquet? *
What brand of tourniquet do you use? *
Does your agency allow the wearing of a tourniquet holster on your duty belt? *
Do you pledge to wear the tourniquet holster as often as possible while on duty? *
Do you agree to replace any broken, lost, or damaged holster? *
Do you agree to report any tourniquet use to the Western Michigan School of Medicine through their on-line reporting form? *
Do you agree to train annually and to remain familiar with proper tourniquet use? *
Are you interesting in becoming a tourniquet trainer? *
What color of holster are you requesting? *
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