Please fill out one request form per request date.Equipment Rental Step 1 of 333%Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Instructor CertificationYou must either have gone through instructor training with us or submit a copy of your instructor certification to be eligible for rental.Max. file size: 256 MB.Adult ManikinMax 12 Price: $15.00 Quantity: Infant ManikinMax 12 Price: $15.00 Quantity: Adult & Infant Manikin SetMax 12 Price: $20.00 Quantity: BVMMax 4 Price: $10.00 Quantity: AEDMax 6 Price: $10.00 Quantity: AHA DVDs Price: $10.00 Quantity: AHA DVDs BLS HeartsaverTotal $0.00 Pick Up Date* MM slash DD slash YYYY Additional NotesRental Period*Rental period is for 48 hours unless specifically noted otherwise. I agreeDamages*Any equipment destroyed or damaged during the rental period is the responsibility of the individual renting the equipment and replacement costs will be charged at current retail price. I agreeDeposit*A $20 deposit required to hold your reservation, which will be applied to your total balance. Balance will be charged upon return. I agree
