TOP Program Agency Request
Use this form is you are an agency applying for the TOP program
Your agency name. Please type complete name. *
Your answer
Your title or rank *
Your answer
First Name *
Your answer
Last Name *
Your answer
Email *
Your answer
Phone Number *
Your answer
Does your agency already possess tourniquets? *
What brand of tourniquet do you use? *
How many holsters are you requesting? *
Your answer
Does your agency allow the wearing of a tourniquet holster on your duty belt? *
Do you pledge to require tourniquet holsters be worn 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 or officers annually and to remain familiar with proper tourniquet use? *
Do you agree to maintain a tourniquet trainer on your staff? *
Do you agree to replace any tourniquet used, lost, or damaged? *
What color of holster are you requesting? *
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