WESTERN ILLINOIS UNIVERSITY
Equipment Loan Form
Tag No. Description
Serial
Number
Purchase
Date
Purchase
Price
If the equipment being loaned will b
e located off-campus, please state the business purpose of the loan:
___________________________________________________________________________________________________
I certify that ________________________ has received the equipment listed above as a temporary loan. The equipment
scheduled return date is ________________. Equipment listed above shall be returned by the scheduled return date or upon
five days’ notice form the WIU inventory custodian in the condition in which it was received.
Released by: _________________________________________ ______________________
Inventory Custodian Date
I agree to be fully responsible for equipment listed above and further agree to be responsible for any costs of repairing the
equipment if damaged while in my possession or replacing said equipment if it is lost, stolen or if damage is not repairable. I
agree to reimburse Western Illinois University in the amount of the purchase price set forth above in the event the equipment
is lost, stolen or damaged beyond repair. I acknowledge that said equipment is in good and operable condition with the
following exceptions, if any: ____________________________________________________________________________
Received by: ________________________________________ ________________________________________
Responsible Party Loan Address
All equipment loan periods exceeding 30 days require the approval of the following:
- Inventory Custodian’s Dean (if applicable); AND
- Associate Provost/Associate Vice President for Academic Affairs OR in the case of non-academic units the
Inventory Custodian’s respective Vice President AND -
Executive Director of Personnel and Financial Affairs
Approval of the Inventory Custodian’s Dean (if applicable) and Vice President is required prior to submitting
the Equipment Loan Form to the Executive Director of Personnel and Financial Affairs.
Approval: ________________________________________ AND Approval: ___________________________________
Dean (if applicable) Associate Provost/Associate Vice President for
Academic Affairs OR Respective Vice President
AND Approval: ___________________________________
Executive Director of Pers
onnel and
Financial Affairs
To be completed upon return of equipment:
I certify that the above listed equipment was returned to me on __________________________. I have examined the
equipment and acknowledge it is in good and operable condition unless otherwise noted.
Inventory Custodian: ________________________________________
Once form is complete, please send to PARC via campus mail or scan and email to parc-g@wiu.edu
