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Request for Off-Site Equipment Utilization

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

Contact Information

First Name

Answer required for "First Name"

Last Name

Answer required for "Last Name"

DOE Email

Answer required for "DOE Email"

Mobile Phone

Number Required

District

Answer required for "District"

Equipment Information

Item Description

Laptop, desktop, printer, etc....

Answer required for "Item Description"

Model Number

Answer required for "Model Number"

Serial #

Answer required for "Serial #"

Asset Tag

Answer required for "Asset Tag"

CONDITION OF EQUIPMENT

New, Used, damaged, etc...

Answer required for "CONDITION OF EQUIPMENT"

CURRENT SITE INFORMATION

School, Address of the school, room #, etc....

Answer required for "CURRENT SITE INFORMATION"

ADDRESS OF PROPOSED OFF-SITE LOCATION

Answer required for "ADDRESS OF PROPOSED OFF-SITE LOCATION"

Reason for off-site equipment use:

Answer required for "Reason for off-site equipment use:"

EXPECTED DATE OF EQUIPMENT RETURN TO SITE

Answer required for "EXPECTED DATE OF EQUIPMENT RETURN TO SITE"

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. If the item is lost, stolen, destroyed or otherwise rendered inoperative through my neglect, I agree to reimburse the Department of Education for the item at replacement value. If the item is damaged, I agree to pay for its repair."

Signature*

Signature Required

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"