ADE ASSISTIVE TECHNOLOGY SHORT-TERM LOAN LIBRARY LOAN REQUEST FORM

CONTACT INFORMATION

Borrower Name *

First Last

School District *

Special Ed.Director/Administrator *

School *

Mailing Address *

(Use street address for delivery, not a PO box.)

Street Address Address Line 2 City State ZIP Code

Email *

Enter Email Confirm Email

Daytime Phone Number *

Extension

(if applicable)

Fax

Send Attention to

(if different from above)

Ship / Pickup *

I would like the loan shipped to me at the above address
I will pick up the loan at 300 W. Clarendon Ave., Suite 475 in Phoenix (AzTAP office) after being informed that the loan is ready. Hours are 8-5, Monday-Friday.

ITEM(S) REQUESTED

(Include components such as key guards. For questions about items in the Loan Library, call AT Loan Library at 602-776-4659 or 800-477-9921)

Items *

Click the + button to add up to 5 items

Item Name	Inventory ID Number

Comments

PURPOSE OF LOAN *

(Select primary reason.)

Consideration / Assessment
Serve as loaner during device repair or while awaiting funding
Provide an accommodation on a short-term basis
Professional development

IS THIS YOUR FIRST TIME BORROWING FROM THE LIBRARY? *

No
Yes

IS YOUR REQUEST THE RESULT OF ATTENDING AN ADE TRAINING? *

No
Yes

Please specify which training(s) *

Terms of Agreement *

As approved ADE Loan Library borrowers, we agree to:

Assume responsibility for returning equipment by the stated due date. Usual loan period is 4 weeks. (Equipment MUST be returned in its original packing container using the prepaid shipping label in order for the library to efficiently track late, lost, or damaged equipment. This requirement is both for your protection and ours. Failure to return equipment on time may result in late charges.)

Obey software and other copyright laws. We willnot make copies of borrowed books, videos, software, and other copyrighted materials. We will remove borrowed software programs that were temporarily installed on any of our computer hard drives prior to returning the original software to the Loan Library.

Follow all stated procedures for requesting equipment from the Loan Library. Immediately notify AT Loan Library at 602-776-4659 or 800-477-9921 or at ATLoanLibrary@Nau.Edu if equipment malfunctions or ceases to operate. No attempts to repair malfunctioning equipment will be made without authorization.

Assume responsibility for the cost of repairing equipment damaged as a result of abuse, neglect, or carelessness. Reimburse the ADE Loan Library at current market value, if the equipment is lost, stolen, or damaged beyond repair.

Acknowledge that this agreement is in effect for up to one (school) year period and must be renewed annually.

Return all equipment by the end of the school year regardless of due date.

Complete the Short-Term Loan Library Feedback Form.

Have our Loan Library privileges suspended or revoked if we do not abide by these requirements.

I agree to the Terms of Agreement

Signature *

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