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Written Authorization Form

Authorization Form for Digital Equipment

This form must be completed by a faculty or staff member prior to to a designee
picking up equipment from Learning Support Services.

The following person has been authorized by me to pick up/deliver equipment
for instructional or events use.

Name _____________________________________________

Email Address ______________________________________

Dates of Authorization:

From:  ____________________ To: ____________________


Approved by:

Name _____________________________Phone __________

Email Address ______________________________________

Date of Approval ___________________________________

I understand that I am responsible for the equipment use and return
at the designated time.


________________________________        ____________________________
Signature of Faculty/Staff Member             Date of Approval