Isle of Wight Ambulance Training and Community Response Services Automated External Defibrillator Order Form

Organisation Name

Contact Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Contact Telephone Number

Invoicing Contact Name (If different)

Invoice Address (If different)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Invoicing contact phone number (if different)

Purchase Order Number (if required on invoice)

If you have a purchase order number please ensure you enter it in this box

Package Required (Please select)

Please select the model and package you wish to order

Requested Delivery Address

If you would like to collect the order from us please enter our address, 18 Barry Way, Newport, Isle of Wight PO30 5GY

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Order Terms and Conditions

I understand that completion of this form acts as a firm commitment to purchase the selected defibrillator package and that subsequent cancellation may result in cancellation charges being applied.

I confirm that I am over 18 years of age and am either responsible for providing funds for the purchase myself or am authorised to submit this order by the Company for whom I am completing this form. Ticking of this box constitutes an electronic signature of acceptance of our Terms and Conditions

I understand that to claim the 10 year warranty, I must register the defibrillator with Wel Medical: iPAD AED – Member Site (ipad-aed.com)

Select Use of the information you have supplied1

We need to use the information provided to process the order you have requested. Please select below to let us know your preference.

Signature providing authorisation to place order

Electronic signatures are acceptable