OFFICIAL REQUEST: For use of equipment/camera
I would like to request permission to use the following equipment from the Ofce of Administrative Services and
Marketing
____ Nikkon Camera
____ Camera lens
____ Lens cap
____ Memory card (4gb or 8gb)
____ Camera Bag
____ Other. Please explain: _______________________________________________________________________________
The equipment will be used for the following purpose:
The equipment will be used on the following date(s): ____________________________________________________________
I agree to pick up the aforementioned equipment on: ____________________________at ____________________________
(please indicate time) (please indicate date)
I agree to return the aforementioned equipment to the on: ________________________at ___________________________
(please indicate time) (please indicate date)
I, ________________________________________, the undersigned, understand that this equipment is the sole property of
the Ofce of Administrative Services and Marketing. If the equipment, or any portion of the equipment, is lost or
damaged, I accept full responsibility for its replacement, repair or reimbursement, as determined by the Ofce of
Administrative Services and Marketing
Borrower’s Name: (Please print) ___________________________________________________________________________________
Email: ____________________________________________________Telephone: __________________________________________
Address: _______________________________________________________________________________________________________
Student organization, club, or ofce afliation: ___________________________________________________________________
Borrower’s Signature: ____________________________________________________Date __________________________________
All request must be approved by the Department Head before submitting to the Ofce of Administrative Services
and Marketing.
Name of Director/Department Head: (Please print) ________________________________________________________________
Email: ____________________________________________________Telephone: __________________________________________
Signature of Department Head (i.e. director): _____________________________________Date: _________________________
Please submit this form via email to studentmkt@nova.edu or drop off to the Office of Administrative Services and
Marketing at least one week before the date of equipment pickup, so we can let you know of availability. You will
then receive and email confirmation from us. Please contact studentmkt@nova.edu regarding this request.