Madison County Extension Equipment Checkout Form

Madison County Extension Equipment Checkout Form
Date

MonthDayYear
Date
Name

First NameLast Name
Email
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Checked Out Equipment

TabletProjectorSpeaker and Mic SystemLaptopCablesChick Hatching Kit4-H CurriculumRobotics EquipmentSoil ProbeHay ProbeLivestock TaggerBlender BikeOther
If you selected the 4-H Curriculum, Robotics or Other box please explain:
Date you Plan to Pick Up Equipment:
Return Date:
By signing below, the recipient takes the responsibility for any kind of damage to checked out equipment and acknowledges that the equipment is working properly and in a good condition. For any loss or damage, the recipient accepts to cover the cost of new equipment.

If it is past the return date Madison County Extension and Outreach reserves the right to invoice you for the equipment borrowed.
Signature

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Date

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Date
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