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Equipment Loaner Program
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Equipment Loaner Program Form
Equipment Loaner Program Form
To reserve the loaner equipment, you must read and complete this form. Be sure to fill out all of the information. Once you have received an email approving your request. Please come to the Help Desk located in room 112 of the IT Convergence Center to check out the equipment.
Employee Information
Employee Name
*
First
Last
UMW Email
*
Work Phone
*
Office Location
*
BLDG Room
Department
*
Campus
*
Fredericksburg
Stafford
Equipment Loaner Agreement
Date From
MM
DD
YYYY
to
MM
DD
YYYY
Equipment Requested
Adapter: Mini Display Port to VGA
Adapter: Regular Display Port to VGA
Card Reader
Digital Camera
Digital Video Camera
Laptop (Mac)
Laptop (PC)
Projector
Screen
Agreement
Financial Responsibility: The department of the Equipment Loaner Program employee must agree to accept full financial responsibility for the costs associated with repair and/or replacement of the loaner equipment if it is damaged, lost, or stolen. If the loaner equipment is damaged, lost, or stolen, the faculty member will be required to notify the DoIT Business Office immediately and work with Campus Police as deemed appropriate.
Employee Signature (upon checkout)
________________________________________________
DOIT Signature (upon checkout)
________________________________________________
For Office Use Only
Equipment Being Checked Out
Any damage to equipment being checked out?
Yes
No
Other: __________________________________
Checkout Date
MM
DD
YYYY
Return Date
MM
DD
YYYY
Any additional damage to the equipment?
Yes
No
If yes, please specify
Employee Signature (upon return)
________________________________________________
DOIT Signature (upon return)
________________________________________________
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