SPECIAL ED TEACHER PIPELINE GRANT EQUIPMENT CHECKOUT

SPECIAL ED TEACHER PIPELINE GRANT EQUIPMENT CHECKOUT
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number*
District*
Supervisor*
Checked Out Equipment

LaptopLaptop Carrying CaseChargerMouseHeadphone
Laptop Asset #
By signing below, the employee 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 employee accepts to cover the cost of new equipment.
Signature

Clear
Should be Empty: