July 18, 2017

July 2017
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Organisation

Contact Person

Position

Phone

Email

Organisation Web Address

Organization Social Media Accounts (IF APPLICABLE)

Facebook Page

Instagram Page

Other

Would a new defibrillator be a replacement for an existing unit, an additional unit or the only unit for the organisation?

Replacement
Additional
Only Unit

BY COMPLETING THIS FORM YOU ACKNOWLEDGE THAT YOU ARE AUTHORISED TO ACT ON BEHALF OF THE ORGANISATION YOU ARE REPRESENTING. COMPLETING THIS FORM IS NOT A GUARANTEE THAT SUNBURY CONNECTED COMMUNITIES WILL PROVIDE A DEFIBRILLATOR TO THE NOMINATED ORGANISATION. IF A DEFIBRILLATOR IS SUPPLIED ALL TRAINING, ONGOING MAINTENANCE, SERVICING AND SUPPLY OF CONSUMABLE PRODUCTS IS THE REPONSIBILITY OF THE RECEIVING ORGANISATION. DEFIBRILLATORS BEING OFFERED ARE A SINGLE USE PORTABLE DEVICE.

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Organization Social Media Accounts (IF APPLICABLE)