Defibrillator Application Form
if you have any questions please contact 02922 402670 or sharon@welshhearts.org
Name of organisation *
Your answer
Organisation address *
Your answer
Main contact name *
Your answer
Position *
Your answer
Phone number *
Your answer
E-mail *
Your answer
How many defibrillators are requested? *
Your answer
Do you have any defibrillators at present? *
Please state the proposed location details for each defibrillator requested and an approximate number for how many people use or visit the location each year *
Your answer
Please explain the reason(s) for applying for a defibrillator *
Your answer
Please provide any other relevant information
Your answer
Would you be prepared to have some modest publicity involving your organisation and Welsh Hearts if your application is approved?
Would you be prepared to help Welsh Hearts in supported fund-raising events where possible?
Why have you chosen Welsh Hearts to supply you with your Defibrillator and training, how did you hear of us?
Your answer
Funding / Invoicing
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