Hampshire Project Club Cricket Charity V2 Order Form

Club Cricket Charity Order Form

Hello, and welcome to The Community Heartbeat Trust, the UK’s leading community defibrillator organisation. Please complete this form as fully as possible and once submitted we will get straight to work processing your request!
Cricket Club Name *
Please provide the name of cricket club or organisation you are ordering on behalf of.
County *
Equipment Selection

Please click/tap on the button below the equipment image to select.
Defibrillator Equipment *

Lifeline View Defibrillator
Annual Support Cost £
Charged per year
Awareness Session
CHT include the awareness as part of your project.
Lead Contact Details

This person will be the central point of contact for the purposes of implementing and discussing your defibrillator project.
Lead Contact *
Lead Contact Name
Phone Number *
Mobile Number
Optional
E-mail *
example@example.com
Correspondence Address *

Street Address

Street Address Line 2

City County

Post Code
This address will be used for the purposes of posting information, paperwork and any other associated articles that relate to your defibrillator project.
Delivery Contact Details

This person will be the main contact and recipient for the delivery of the defibrillator equipment.
Is your delivery address the same as above?

Yes No
Delivery Contact *
Delivery Contact Name
Contact Number *
Mobile Number *
Delivery Contact E-mail *
example@example.com
Delivery Address *

Delivery Address

Delivery Address Line 2

Delivery City Delivery County

Delivery Post Code
Defibrillator Location
Defibrillator Location *

Portable Unit - Kept with individual
Keepers Address

Location and contact persons details of where your portable unit will be kept/stored when not in use during practice or matches.
Is the Keepers Address of the equipment the same as one of your previous addresses?

Yes - Correspondence Address Yes - Delivery Address No
Keepers Name *
Keepers contact name
Keeper Contact Number *
Keepers Phone Number
Keepers Contact E-mail *
example@example.com
Defibrillator Keepers Address *

Keepers Address

Keepers Address Line 2

Keepers City Keepers County

Keepers Post Code

Managed Solution Agreement
Managed Solutions Agreement *
*Please read/scroll to the bottom of the conditions. You will then be able to click agree.

The signature fields below can be completed using your mouse or finger if on phone or tablet.
Managed Solution Signature *

Clear
Signed for on behalf of the Community Heartbeat Trust
Terms & Conditions

Please Read/scroll to the bottom of the terms outlined below and click agree otherwise you will not be able to submit.
Send a copy of this form to my e-mail for my records *

Agree No Thank You
Should be Empty:

Club Cricket Charity Order Form

Equipment Selection

Lead Contact Details

Delivery Contact Details

Defibrillator Location

Keepers Address

Managed Solution Agreement

Terms & Conditions