Name _____________________________________________________
Department________________________________________________
Office phone______________________________________________
Home phone________________________________________________
Type of hardware/software requested:
__________Laptop
__________Removable hard drive
__________Floppy disks
__________CD-Roms
__________Laptop
__________Other (describe)________________________________________
If sofware, description of information contained thereon___________________________
___________________________________________________________________________________
Date and time of removal _______________________________________
Date and time of return_________________________________________
Reason for removal from [Insert name of organization]
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
I understand by siging this form and removing the hardware or software from [Insert name of organization], I am responsible for safeguarding the equipment or software from harm and unauthorized use by any person other than myself. Family members or others residing with or visiting me will not be provided with passwords or other means of access to any information stored on or in the checked-out equipment
_________________________________________
Signature and Date