Portable Equipment Loan Request (2009-10)

This form is to be completed by USI EMPLOYEES to borrow equipment for university-related activities, and is NOT for personal use. A university account number is required- charges may apply. Questions? Contact us online at instructech.usi.edu , or call us at 464-1838.

1. Please type your name.

Please type your name.

2. Please type your complete EMAIL address.

Please type your complete EMAIL address.

3. Type the telephone number where you may be reached if we have any questions.

Type the telephone number where you may be reached if we have any questions.

4. Select area where you work at USI.

Select area where you work at USI.

5. Type in your departmental ACCOUNT NUMBER and the FISCAL AGENT'S NAME on the account. This account will be charged in the event the equipment is damaged. The fiscal agent should email ITS their approval.

Type in your departmental ACCOUNT NUMBER and the FISCAL AGENT'S NAME on the account. This account will be charged in the event the equipment is damaged. The fiscal agent should email ITS their approval.

6. State the meeting or the purpose for the loan.

State the meeting or the purpose for the loan.

7. Select the equipment you need from the list below:

Select the equipment you need from the list below: AVP player (combination player- plays dvd's & vhs tapes)

Boombox- w/CD player & cassette tape player

Cassette tape recorder

DVD player

Easel

Easel paper pad (May be purchased from ITS, fiscal approval and account number needed.)

Extension Cord

Flip video camcorders (download up to 60 min video to Internet)

Laser pointer

LCD data projector (projects computer images)

MP3 digital recorder

Overhead transparency projector

Portable sound system

Projection Screen

Scan converter (projects computer images on TV)

Slide projector

Slide projector w/ slide tray (holds 80 slides)

Sony Cybershot (digital camera)

Sony Mavica (records to floppy disc)

Sony mini digital-video recorder (must buy dv tapes from ITS OR elsewhere)

Need more than one of any item listed? (please specify)

8. Didn't see what you need on the list above? Please Note: WE DO NOT HAVE ANY COMPUTERS.

Didn't see what you need on the list above? Please Note: WE DO NOT HAVE ANY COMPUTERS.

9. What date will you need to pick up equipment?

What date will you need to pick up equipment?

10. Type the time you need to pick up the equipment. PICK-UP TIMES ARE: M-F 8:00 a.m. to 4:15 p.m.

		HH		MM	AM/PM
Pick up time:		Type the time you need to pick up the equipment. PICK-UP TIMES ARE: M-F 8:00 a.m. to 4:15 p.m. Pick up time: Hour	:	Minute	AM or PM

11. What date will you return equipment?

What date will you return equipment?

12. Time you will be returning equipment. RETURN during business hours: M-F 8 a.m. to 4:15 p.m.

		HH		MM	AM/PM
Return time:		Time you will be returning equipment. RETURN during business hours: M-F 8 a.m. to 4:15 p.m. Return time: Hour	:	Minute	AM or PM

13. IF THIS DOES NOT APPLY, skip question. Select box if you have questions or need assistance.

IF THIS DOES NOT APPLY, skip question. Select box if you have questions or need assistance. I will need a demonstration on the equipment.

I have a question; please contact me.

PLEASE PRINT A COPY of this completed form for your records and review it before continuing.