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Info Line: 1.800.59.AMKUS

PLEASE NOMINATE SOMEONE THAT USED AN AMKUS TOOL FOR RESCUE

Please fill out the form below
Agency Information
Agency: *
Contact: * 
Telephone: * 
Fax:
Email: *
Agency Address 1:
Agency Address 2:
City:
State:
Zip:
Country:
Incident Information
Date of Incident: *
Location of Incident: *
Names and titles of individuals that directly supervised, actually operated, or provided direct assistance to the operators of the AMKUS Rescue System: *
Brief description of the incident, explain how the nominee was assisted by the AMKUS Rescue System:
 
* Denotes Required Field

IMPORTANT NOTE:

A copy of the Incident Run Report MUST accompany nomination.

Please email, fax or mail the Incident Run Report as soon as possible.

Confidential patient information can be deleted.

 
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