CENTRAL CONNECTICUT STATE UNIVERSITY
OFF-CAMPUS EQUIPMENT LOAN
Instructions:
1. Recipient fills out Section 1.
Signatures Required: Dept. Head
and Chief Officer or area Vice-President.
Dept. Head retains a copy and forwards the original to Property Control Manager.
2. Upon return of equipment: Dept. Head or Chief Officer or area Vice-President fills out Section 2,
retains a copy and forwards the original to Property Control Manager.
3. This form must be renewed annually.
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SECTION 1
Original or Renewal Date Loaned:_________________ Expected Date of Return:_____________________(Max. 1 year)
Room______________Bldg.____________________Dept._________________________________________________
To Location:______________________________________________________________________________________
Print Complete Address
Purpose:__________________________________________________________________________________________
Bar Code Serial No. Description/Condition Value
1.
2.
3.
The recipient is responsible for providing due care and security of the above-described equipment while off the University’s premises.
In the event of a theft or malicious damage, a copy of a police report must accompany the notification to the Property Control Manager.
The University will investigate the matter and if the employee is found to have been negligent, (s)he may be held responsible for
replacing the equipment and may be subject to disciplinary action. If the investigation determines they were not negligent, the
University will take responsibility for replacing the equipment. The recipient will bear responsibility for the return of this equipment in
the same condition as at the time of release, as reasonably expected.
_____________________________________________ ____________________________________
Recipient Signature Date Printed Name Date
_____________________________________________ ____________________________________
Dept. Head Signature Date Printed Name Date
_____________________________________________ ____________________________________
Vice-President/Chief Officer Signature Date Printed Name Date
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SECTION 2
Date ____________ The above equipment has been returned to Room ______________Bldg. ________________________________
Dept.____________________________________________in the same condition as it was accepted at the time of the loan, where
reasonably expected.
Please note any exceptions:______________________________________________________________________________
____________________________________________________________________________________________________
Received by: _______________________________________ _________________________
Dept. Head or Chief Officer or Vice-President Date
Rev. 04/06
