NATIONAL INSTITUTE FOR CARDIAC EDUCATION, Inc.

A 501 (c) 3 Charitable Organization – Federal ID number 65-0902743

Providing Cardiovascular Health Education and Assistance to Patients, Healthcare Professionals and the Community
3702 Washington Street – Suite 304 – Hollywood – Florida - 33021

Application for Defibrillator Donation

This application needs to be completed in its entirety and faxed back to (954) 967-9961 in order for it to be considered by the National Institute for Cardiac Education, Inc. Defibrillator Placement Committee.

Fields marked (*) are required

Full Name*
Email*
Address
City
State
Zip Code
Phone
Cell
Candidate Establishment Name:
How many visitors/customers and/or employees are in the above mentioned location on a daily basis?
Have you had any cardiac incidents at this location?
If so, How many incidents during the last two years?
What are the hours of operation?
Please give a brief description/history of your establishment
Why do you think that your establishment is a good candidate for the donation of an AED?
Additional Comments

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Phone (954) 964-2216 – Fax (954) 967-6551
 

N.I.C.E. Charities
National Institute for Cardiac Education
3702 Washington Street—Suite 304
Hollywood, FL 33021
Phone (954) 964-2216
Fax (954) 967-6551
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