Employer: [EMPLOYER NAME] Supervisor: [SUPERVISOR NAME]

Name: [EMPLOYEE NAME] Address: [EMPLOYEE ADDRESS]
Phone #: [EMPLOYEE PHONE #] Employee #: [EMPLOYEE ID #]
Position/Title: [EMPLOYEE POSITION/TITLE]

Make: [EQUIPMENT MAKE] Model: [EQUIPMENT MODEL]
Serial #: [EQUIPMENT SERIAL #]
Additional Info: [ADDITIONAL INFORMATION]

By signing this form, I, the employee, acknowledge that the equipment above is in working order and that I agree to the following terms:

1. The equipment is to be used for company purposes only;
2. If the equipment is damaged (excluding normal wear and tear), lost, or stolen outside of company premises or off company time, I am responsible for any repair or replacement costs; and
3. Upon separation from the company, I will return the equipment in good working order. If I fail to return the equipment upon separation from the company, or if it is damaged (excluding normal wear and tear), I authorize a payroll deduction to cover any replacement costs the company might incur.

Employee Signature:                                                               Date: ______________
Print Name:[EMPLOYEE NAME]