Southern Illinois University Equipment Checkout Form
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1Computer Learning Center 5 (CLC 5)
Equipment Checkout Form
Borrower’s Name: ________________________________________________________
Faculty/Student ID #: ______________________________________________________
Contact Phone #: _________________________________________________________
SIU Tag #: ________________________________________________________ ______
Equipment Make & Model: _________________________________________________
Item Description: _________________________________________________________
Accessories Included: _____________________________________________________
Checkout Date: From _________________________ To _______________________
Borrower Signature: _______________________________________________________
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Computer Learning Center 5 (CLC 5)
Equipment Return Receipt
Borrower’s Name: ________________________________________________________
SIU Tag #: ______________________________________________________________
Equipment Make & Model: _________________________________________________
Item Description: _________________________________________________________
Accessories Included: _____________________________________________________
Is all equipment present and operational? ❑ yes ❑ no ________________________
CLC 5 Staff Signature: _____________________________________________________
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