REQUEST TO BORROW BELLEFONTE BOROUGH
PROPERTY/EQUIPMENT
Today’s Date _________________
REQUESTOR INFORMATION
Applicant Name:
Address:
Home Phone: Work: Cell:
Email:
Item
Qty
Condition
Replacement
Value
Current Value
The equipment shall be loaned from __________________________ until __________________________,
the loan period. The loan period may be extended by mutual consent of both parties.
No variation or amendment o this agreement will be effective unless it is made in writing; this can be by
email.
The Applicant must arrange a mutually convenient time to collect the equipment on the first day of the loan
period and to return it on the last day of the loan period.
Title and all rights to the equipment shall at all times remain with the Borough of Bellefonte. The Applicant
acknowledges that it has no right, title or property in the equipment.
Risk of any loss or damage to the equipment will become the responsibility of the Applicant upon it leaving
the Borough of Bellefonte’s possession and shall not revert back to the Borough of Bellefonte until the
equipment is back on the owners premises.
The Applicant agrees that during the loan period it shall:
o Keep the equipment in its possession and control and ensure that it is secure against loss, damage
and theft.
LOAN INFORMATION
Pick up time/date ___________________
Due Date___________________
Purpose of use: ____________________
_________________________________
o Keep the equipment in good working order, fair wear and tear excepted.
o Ensure that identification marks or labels on the equipment are not removed, defaced, amended
and obscured including those which identify the equipment as belonging to the Borough of
Bellefonte
In the event of the equipment being lost or damaged, the Applicant agrees to pay a replacement cost.
Signed on behalf of the Borough of Bellefonte
Signature______________________________________________ Date __________________________
Print Name ____________________________________________ Position ________________________
Signed on behalf of the Applicant
Signature______________________________________________ Date __________________________
Print Name ____________________________________________ Position ________________________
I HEREBY RELEASE FROM LIABILITY AND AGREE TO INDEMNIFY AND HOLD HARMLESS THE BOROUGH OF
BELLEFONTE, AND ANY OF ITS EMPLOYEES, AGENTS OR VOLUNTEERS REPRESENTING OR RELATED TO
THE BOROUGH OF BELLEFONTE, FOR ANY LIABILITY IN CONNECTION WITH THE USE OR POSSESSION OF
THE EQUIPMENT. THIS RELEASE IS FOR ANY AND ALL LIABILITY FOR PERSONAL INJURIES (INCLUDING
DEATH) AND PROPERTY LOSSES OR DAMAGE OCCASIONED BY, OR IN CONNECTION WITH THE
POSSESSION OR USE OF THE EQUIPMENT.
___________________________________________
Signature
___________________________________________
Print name
__________________________________
Date
RETURNED:
Borough of Bellefonte Initial _____________
Applicant’s Initial _____________
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