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Equipment Utilization

Please complete the form below. Required fields marked with an asterisk *

Equipment Utilization*

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Off-Site Use

In School Use

Equipment Information

Item Description*

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Model Number

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Serial Number

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Asset Tag Number

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Reason for off-site equipment use:

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Address of proposed off-site location:

Street Address

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City

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Zip/Postal

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Date of Equipment Transfer*

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Expected Date of Equipment Return to Site*

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Borrower's Agreement

I agree to be responsible for the designated equipment item while it is in my possession and to return it by the above indicated date. I th item is lost, stolen, destroyed or otherwise rendered inoperative through my neglect, I agree to reimburse the Department of Education for the item at the replacement value. If the item is damaged, I Agree to pay for its repair. *

By typing your name in the space below, you agree to the above statement.

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Confirmation Email

Confirmation Email *

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