Application for Defibrillator Pad Reimbursement

Application for Defibrillator Pad Reimbursement

Causeway Coast and Glens Borough Council will reimburse the cost of replacement pads for automated external defibrillators that are located within the Borough and registered on the British Heart Foundation circuit

Name of Applicant

Address of Applicant

Postcode

Home Phone

Mobile

Location of Defibrillator

Date of Defibrillator activation

Is the device registered on the British Heart Foundation circuit?

Yes

Cost of replacement Pads

Bank Details

Name of Bank

Sort code

Account No

Please upload the receipt and bank statement for the replacement Pads. Photographs of receipts and bank statements are acceptable.

Drag and drop files here or click to upload