Nutrition Warehouse Check-Out Form

Please complete the form below to check out property/equipment from the Nutrition warehouse for district-approved purposes.

Requestor's first and last name:*

First NameLast Name

Requestor's email address:*

example@example.com

Requestor's phone number or extension:*

Department/School*

Other Department/School

Item Description: *

Quantity:*

Purpose: *

I would like to check out the requested property/equipment for the following period of time:

Checkout Date:*

Checkout Time:*

00:00 Minutes

AM/PM Option

Anticipated Return Date:*

Anticipated Return Time:*

00:00 Minutes

AM/PM Option

Are you requesting item delivery?(**If you are requesting items be delivered and/or picked up by Nutrition warehouse personnel, your request must be submitted a minimum of 10 business days prior to delivery.)*

YesNo

Delivery Location:*

Requested Delivery Date:*

*Must be at least 10 days from today.

Requested Delivery Time:*

00:00 Minutes

AM/PM Option

Anticipated Pickup Date:*

Anticipated Pickup Time:*

00:00 Minutes

AM/PM Option

Please read the following and check the boxes:*

If not requesting delivery, I understand that it is my responsibility to pick up the property/equipment and to return it to the same location at the end of the use period. (If requesting without 10 day notice, you will need to pick up, as delivery is not available on short notice.)I agree to return the Property/Equipment in the same condition that it was in on the day I checked it out.

I understand that there is no charge to checking out the Property/Equipment. However, in the event that the Property/Equipment is lost or destroyed during the use period, I agree to replace the Property/Equipment at my department's expense. Further, if the Property/Equipment is damaged during the use period, I agree to have the Property/Equipment fixed or replaced. If I do not return the Property/Equipment at the end of the use period set out above, or fix or replace the property/equipment within thirty (30) days of the end of the use period if the Property/Equipment has been damaged, I agree to the following:*

I authorize RSD Nutrition Services to send appropriate charges to my department should the property/equipment need to be repaired or replaced.I understand that RSD Nutrition Services may charge additional fees based upon the conditions necessary to replace or fix property/equipment.

RSD Nutrition Services will contact requestee prior to any charges being applied.

Please initial here if you agree to the above terms:*

Budget Code:*

(required for request to be processed)

I hereby release from liability and agree to indemnify and hold harmless the RSD Nutrition Services department and any of their employees or agents for any liability in connection with the use or possession of the property/equipment. This release is for any and all liability for personal injuries, property losses, or damage occasioned by, or in connection with, the possession or use of the property/equipment.

Name of Staff Member Checking Out Property/Equipment:*

By typing your name below, you are signing this application electronically.

Today's Date:

Date