Facilities And Services Equipment Request/checkout Form - Nm State University

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Facilities and Services
Equipment Request/Checkout Form
Requestor Information
Name: _______________________________
Department: ____________________________
Date: _____________________
Purpose for equipment use:
Equipment
Serial
Expected
Description
Bar Code No.
No.
Date Received
Return Date
Date Returned
Release of Liability
I, _______________________ acknowledge that the equipment is in good working condition and that I have
examined the equipment to ensure that it is free from defects. I also understand and agree that the lender shall
not be held liable or responsible in any way for any injury, death or other damages which may occur as a result
of the rental and/or use of the equipment. I assume sole liability for any charges for any such injuries or
damages and agree to pay full replacement cost in the event of any lost, stolen, or damaged equipment.
______________________________
______________________________
________________
Borrower Print Name
Borrower Signature
Date
______________________________
______________________________
________________
Supervisor Print Name
Supervisor Signature
Date
______________________________
______________________________
________________
Director Print Name
Director Signature
Date
Updated: 5/6/2014

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