Facilities Department - 419-755-4855 ~ Property Use Policy 17-40 Last revision 3-15-12
Facilities Equipment Loan Form 17-401c
This form is to be used when a piece of equipment is being loaned to an organization independent of the college or to
college employees who will take the equipment off-campus.
Date of loan _______________ Date equipment is to be returned by (date) ______________
Department ________________________________________ Department number _____________
NC State Tag # Serial # Description
Approvals
_______________________________ ___________ ______________________________ ___________
Dean/Supervisor Date Area Vice President Date
______________________________ ____________
Vice President of Business & Finance Date
I agree that the above equipment has been received and is on temporary loan to:
Company/Individual Name: __________________________________________ Phone _____________________
Street: ______________________________________ City: ___________________ State: _________ Zip: _______
and that (name of responsible party)_____________________________ will be responsible for the above equipment
while on our premises.
______________________________ ____________
Equipment Received By Date
Return of Equipment
_______________________________ ___________ ______________________________ ___________
Returned By Date (NCSC) Received By Date
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