Item Use Request Form

Item Use Request Form
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Item(s) Requesting:
How many of each is needed?
Date of pickup

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of pickup

Hour Minutes

AM/PM Option
Date of return

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of return

Hour Minutes

AM/PM Option
**If approved, please return items at specified time. Any item not returned, damaged or left outside of the building is subject to being replaced or paying to cover the cost of that item.**

I understand the terms above and will replace or pay to cover an item if it is lost, stolen, damaged, left unattended outside of the building or not returned.
Signature
Should be Empty: