Equipment Check-out Form

CONTACT INFORMATION

Last Name*

First Name*

cell-phone number*

APSU email*

Complete this section if you need to check-out an instrument (this is for studio and ensemble purposes only. For Group-Instruction classes, see your instructor).

Before you begin completing this form, you will need the make, model, and serial number of the equipment you would like to check-out.

If you need to check-out technology or other equipment, skip this section.

Instrument you need to check-out (e.g. bass clarinet, bari-sax, etc...)

Instrument Brand or Manufacturer

Serial Number

Complete this section if you need to check-out Department of Music Technology. Not all equipment is available to students. See your applied instructor or ensemble director for more information.

Technology you would like to check-out

Video Camera Package (includes camera, power supply, and tripod

MacBook Pro (includes mouse, power cables, external CD, and carrying case)

Kurzwiel Keyboard (includes keyboard stand, Roland Amp, stereo cable, sustain pedal, Gator Case w/ key, and extension cord)

Zoom recorder (includes 2 interchangeable microphones, and case)

Other (provide more information below)

OtherIf you selected 'other,' provide additional information here.

Other Equipment

Music Department Display (larger display)

Music Department pop-up display (smaller)

Music Department Table Cloth

Small folding tables

Other

If you need any additional equipment not listed on this form, describe.

On what day will you return the equpment? *Usually you will discuss a due-date prior to checking-out an item.

RESPONSIBLE PARTY: When equipment is issued to a student, there must be a responsible party. The responsible party is a faculty or staff member who issued the equipment and who is ultimately responsible to ensure the equipment is returned by the due date indicated on the form, in its original condition.

First and Last Name of Responsible PartyRequired for students who wish to check-out university equipment

APSU email of Responsible PartyRequired for students who wish to check-out university equipment

All equipment must be returned on or before the last class day of the semester unless you make other arrangements in advance. Students are responsible for the care and maintenance of equipment while in the student’s possession. Students will be held liable and will be expected to pay for all damages caused by negligence or mistreatment of the equipment while in the student’s possession. Failure to return university-owned instruments within 5 business days of agreed upon due date will result in the instrument[s] being considered lost or stolen. A Notification of Loss Report will be submitted to the Office of Internal Audit and the Vice President for Finance and Administration as required by university policy 1:016. In addition a hold will be placed on the account of the last known borrower until the instrument is returned or replaced. Your signature indicates that all information on this form is complete and accurate and that you agree to the conditions stated above.

By submitting this form, you confirm that all information on this form is complete and accurate and that you agree to the conditions stated above.

Confirmation

I confirm that all information on this form is complete and accurate. I agree to the conditions stated above.