EQUIPMENT LOAN FORM
Upward Bound Program
University of Hawai’i at Hilo
SECTION III: OFFICE USE ONLY
Borrowed Item(s): Laptop: Make: Model: No: ____
Book(s): Title: No:
Other(s): Item: No:
Condition of item(s) upon departure: (ie. working, missing parts, scratches, etc.)
DATE REC’VD (PC): ____ / ____ / ____ DATE BORROWED: ____ / ____ / ____ DUE DATE: ____ / ____ / ____
____________________________________________ , ___________________________________________
Student Last Name (Print) Student First Name (Print)
1. Request to borrow specified item(s):
2. Reason for Specified request (ex. Student will be using the laptop to do scholarship research and college
applications):
I agree to return the borrowed item(s) within one month in the condition that is received. I understand that if
it is not returned in the condition that it was received, my borrowing privileges with Upward Bound will be
terminated. My parents and I also agree that if the item(s) is lost, stolen, and/or damaged we are responsible
for the cost of repair or replacement of the item(s).
Date: _____ / _____ / _____
Signature of Borrower Signature of Parent
Physical Address: __________________________________ City: _________________ State: __________Zip: __________
Home Phone: (______)-_______-_______ Cell Phone: (______)-_______-_______ Email: ___________________________
SECTION IV: RETURN OF LOANED ITEMS(S) DATE RETURNED: _____ /_____ /_____
Condition of item(s) upon returning: (ie. working, missing parts, scratches, any problems, etc.):
________
Date: _____ / _____ / _____
Signature of Borrower
Date: _____ / _____ / _____
Signature of Upward Bound Staff
SECTION II: PROGRAM COORDINATOR APPROVAL
Urban East West North Math Science
Program Coordinator Signature: ____________________________________ Date: _____ / _____ / _____
