CSEMS on line test site registration form

The Central Shenandoah EMS Council offers an equipment loan service to regional instructors. Instructors checking out equipment must adhere to the following policies. The ability of the Council to loan equipment is subject to the availability of the equipment.

1.	Equipment must be reserved at least five (5) business days in advance.
2.	The request must be approved by one of the training staff.
3.	Equipment will not be checked out for more than 5 business days.
4.	Preference will be given to providers and agencies within the CSEMS region.
5.	All equipment must be returned in the condition in which it was checked out.
6.	The person and/or agency that fills out the request form is responsible for replacing damaged or lost equipment.

CSEMS On-line Equipment Reservation Form

Check Out Date:

(mm/dd/yyyy) (Required)

Return Date:

(mm/dd/yyyy) (Required)

Type of Training Class: (Required)

Location where equipment will be used: (Required)

Address

City State Zip Code

Equipment requested (provide itemized list):


Name:	(Required)
E-mail:	(Optional)
Telephone:	(Required) (XXX-XXX-XXXX)
Affiliation:	(Required)

I understand that it is my responsibility to:

1. Return the equipment in a timely manner.
2. Return equipment in reasonable condition.
3. Replace lost or damaged equipment.
4. Adhere to the policies listed above.

Agree Disagree

Reservation Forms for Download

Reservation Form (pdf)	Reservation Form (Word)
Fax: 540-886-3735

Central Shenandoah EMS Council
2312 W. Beverley St., Staunton, VA 24401
www.csems.vaems.org