University of Alaska Fairbanks (UAF) Disability Services Equipment Loan Form

University of Alaska Fairbanks (U AF) Di sabi lity Ser vices

Equipment Loan Form

Student Information

Name (please print):

Last First MI

Home Phone: Cell Phone:

Maili ng Addr es s :

Street or PO Box City State Zip

Home Address:

Street or PO Box City State Zip

Preferred E-mail:

Student I D:

Equipment Inform ation

Item Description:

Item Identification Number: Value:

Terms of Equip m ent Loan

The student assumes full responsibility for this item. Should the item become lost or stolen the student is responsible for

the replacement or cash value of the item. Should the item become damaged the student is responsible for repairs. Any

amount of monetary loss or damage not paid by the student will be forwarded to the UAF Business Office. Registration

materials and transcripts will be held until the amount owed is paid in full.

DISABILITY SERVICES RESERVES THE RIGHT TO RECALL EQUIPMENT AT ANY TIME BASED ON

PRIORITIZATION OF NEED

Agreement

I have read and understand the terms of this equipment loan.

CHECKOUT OUT PERIOD:

DUE DATE:

Student S ign atur e Date

Disability Services Representative Signature Date

Equipment Return Information

(f or Office us e only)

Date Returned: Received By:

Was equipment returned in original state? Yes No

If no, describe:

Fillable Printable University of Alaska Fairbanks (UAF) Disability Services Equipment Loan Form