Banacos Academic Center

Disability Services

ds@westfield.ma.edu

Learning Disabilities Program

ldp@westfield.ma.edu

Banacos Advisor:

Equipment Loan Agreement

Name: UWID (A#):

Phone: (i.e. 555-555-5555)

WSU Email: @westfield.ma.edu

Address:

By signing this document, I hereby recognize that:

I am responsible for all components of (check one):

FM system, including (but not limited to):

Receiver (with charging cord, plug, & audio cable)

Microphone (with charging cord, plug, audio cable, recording cable, carrying pouch, & neck loop)

Manuals

Mac USB adaptor

Plastic carrying box

Other:

QTS System, including (but not limited to):

Laptop (with charging cord & bag)

Ipad (with charging cord & plug)

Wearable Microphone (with base, charging cord, & carrying case)

Conference Microphone (with charging cord, & carrying case)

Mac USB adaptor

Other:

Other:

I am responsible for the loss and/or any damages to the borrowed equipment and all components.

I understand that the borrowed equipment and all components must be returned to the Banacos Academic Center at the mutually agreed upon time written below.

I understand that failure to return the borrowed equipment or any of the components by the agreed upon date may result in being billed for the equipment borrowed/not returned.

Date of loan:

Date of return agreed upon:

Borrower’s Signature:

Staff Signature:

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Actual date of return:

Borrower’s Signature:

Staff Signature: