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By signing this form, I agree to the following: I am responsible for the equipment or property issued to me; I will use it/them in the manner intended; I will be responsible for any damage done (excluding normal wear and tear); upon separation from the Company, I will return the item(s) issued to me in proper working order (excluding normal wear & tear); I will replace any items issued to me that are damaged or lost at my expense; I authorize a payroll deduction to cover the replacement cost of any item issued to me that is not returned for whatever reason, or is not returned in good working order.

Employee Name(Required)
MM slash DD slash YYYY
Example: Compass - Personal Voltage Detector
MM slash DD slash YYYY