£ Evaluation £ Demonstration  £ Trial Use

£  Training £  Other

(other:specify)____________________________________________________________________

_______________________________________________________________________________

EQUIPMENT REQUESTED
Loan limited to 2 items.

Item Name                               Description                                         Value  

1. _______________________________________________________________________

2. _______________________________________________________________________

                                                                             Total Value____________________ Signature______________________________________________

Duration of Loan

£   2 Weeks

£   4 Weeks

£   6 Weeks

£   Other, by special arrangement

If you wish to wait until all items are available to send to you at the same time, please check here.  £

Extensions may be available if the equipment is not on the CSDB Technology Loan Bank Waiting List.

 

SHIPPING INFORMATION

►    ALL return Shipping costs are the expense of the borrower

Address for delivery where someone is available Monday-Friday, 9 AM-5 PM.  Do NOT use a P.O. Box number for a shipping address- you MUST include a street reference.  If delivery is to a large facility, you MUST specify department, floor and/or office number.

 

Full Name_______________________________________________

Title____________________________________________________

Organization/Agency________________________________________

Department_______________________________________________

Street Address____________________________________________

City/State/Zip_____________________________________________

Daytime Phone Number (including area code)

______________________________________

E-mail Address__________________________________________

 

If you will be picking up equipment from CSDB , please check here.  £

 

Returning Equipment to CDSB

CSDB Technology Loan Bank equipment must be returned to CSDB on or before the due date listed on contract.

USPS and UPS address: 

CSDB Technology Loan Bank
attn: Bonnie Ottmar
33 N. Institute St.
Colorado Springs, CO 80903

To return equipment personally, please email techloanbank@csdb.org or call 719-578-2124 to make arrangements

CSDB Technology Loan Bank
Borrower’s Responsibility and Liability Statements

 

Please read and sign BOTH the “Borrower’s Responsibility and Liability” and the “Release of Liability” Statements included in this packet.

The person who is accepting FINANCIAL RESPONSIBILITY for this equipment should sign these statements.

Please note that you must IMMEDIATELY report any missing or damaged items in order to minimize your financial responsibility for replacement or missing or damaged items.  To report missing or damaged items, please call 719-578-2124 or send e-mail to techloanbank@csdb.org and report information to Bonnie Ottmar.

Items must be returned clean, complete and in original operating condition.  A fee may be charged for cleaning, repairs and/or replacement parts or full replacement.  All fees will be based on current replacement value.

BORROWER’S RESPONSIBILITY AND LIABILITY

I understand and agree that I am responsible for proper handling and use of the device(s).

I am responsible for returning all components to CSDB Technology Loan Bank in a timely manner and in accordance with shipping instructions.  If I find that any components listed on the inventory sheet are missing when I open the shipping case, I must call (719-578-2124) or email ( techloanbank@csdb.org ) the CSDB Technology Loan Bank  immediately so I will not be held financially liable for the missing components.

The total replacement value of the item(s) I want to borrow is

$______________________________ plus the cost of shipping.

In case of theft, I will not be held responsible, as long as I immediately notify the police and CSDB Technology Loan Bank.  I must provide a copy of the police report to CSDB.

If an equipment breakage or malfunction occurs, I must immediately notify the CSDB Technology Loan Bank at 719-578-2124.  I will not be held responsible for equipment breakage or malfunction that occurs during normal use as long as I report it promptly.

I understand that it is illegal to copy or distribute any software which is installed on the CSDB Technology Loan Bank equipment.  Upon completion of the loan period, any software that I have loaded on borrowed equipment will be removed.

Failure to comply with these responsibilities will result in loss of future access to the CSDB Technology Loan Bank, in addition to applicable financial responsibility.

_____________________________________________________________

Signature of Responsible Party                                     Date

_____________________________________________________________

Print Name                                                                               Phone

Return your original, completed, signed request form to CSDB at:

CSDB Technology Loan Bank,  Attention: Bonnie Ottmar   33 N. Institute St, Colorado Springs, CO 80903

You may scan and email your request to begin the process but an original copy MUST be on file before equipment will be shipped.

Printable PDF form

last edited: 01/10/2008