DELAWARE HEALTH AND SOCIAL SERVICES
Division of Public Health 
Office of Emergency Medical Services
 
Registration for Automatic External Defibrillator Service Provider 
Delaware Early Defibrillation Program 
First State, First Shock! Program
 
Print Clearly and Answer All Sections Completely 

Type of Application (Check One): 

___ Initial Application (complete all sections)	___ Change (complete appropriate section) 


Agency Name:_____________________________________________________________________________
 
Street Address:__________________________________________________________________________

Mailing Address (if different from above):_______________________________________________

City:_______________________________________________   DE   Zip:_________________________

Service Coordinator:_____________________________________________________________________

Daytime Telephone Number:________________________________________________________________

Pager:___________________________________________________________________________________

FAX:_____________________________________________________________________________________
 
 
Type of Service: 
___ EMS/Fire/Rescue
___ Law Enforcement/Corrections
___ Business/Industrial
___ Senior/Youth Center
___ School/Higher Education
___ Government
___ Healthcare
___ Public Assembly
___ Other (Describe):____________________________________________________________________ 


Provide the following attachment (All entities except Fire/EMS/Law Enforcement):
 
1) Statement from Business or Agency Chief Officer supporting program implementation.


Signature of Service Coordinator:_________________________________________________________

Date:____________________________

************************** OEMS Use Only Below This Line *********************************
 
Reviewed By (Print):___________________________________ Date:_____________________________
 
Status: ___ Entered into system  ___ Awaiting additional information 

Comments:_________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________
FILENAME: AED Application.doc 
Doc. #35-05-20/07/03/22