Academic Learning Center Math and Science Services Center Calculator Borrowing Form orm to

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Academic Learning Center
Math and Science Services Center
Calculator Borrowing Form
Complete form and return it to ITTC 008 or email completed form to [email protected]
Contact Information:
Name:
UNI ID#:
Home Phone Number:
Cell Phone Number:
Email Address:
Equipment Information:
Calculator Model:
Serial Number:
Calculator includes:
ALC Inventory #:
Batteries
 Calculator Cover
PLEASE READ BEFORE SIGNING!
My signature below indicates my consent to the following terms and conditions.
All items are due no later than the Friday of final exam week each semester. If calculators are needed
for the academic year, they must be returned and checked out each semester.
I will return the above checked item by ________________ on __________________________.
time
date
I understand that failure to return the above named item as stated below to the Academic Learning
Center representative or to the Math and Science Services Center Coordinator at 008 Innovative
Teaching and Technology Center will result in a charge to my University Bill in the amount of current
replacement cost for all items. I am also responsible for costs associated with repairs of the item and/or
replacement of any missing parts that accompanied the item.
Print Name:
Signature
Date:
For Staff Use Only
Staff: Please indicate any damages to the calculator and indicate that all materials issued were returned.
Batteries
 Calculator Cover
Defects/Damages:______________________________________________________________________
_____________________________________________________________________________________
Checked Out by:
date:
Checked in by:
date:
Revised 5/14/2014 LH
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