2. First Name*
3. Last Name*
5. Address*
7. City*
8. State
9. Zip Code
11. Phone Number*
12. Email Address*
14. Equipment *
    -- Select One --Sony PXW-X70 Digital Camcorder Comes with shoulder bag, headphones, shotgun microphone, battery pack, power cable, and SD card recording media.Tripod for Camera
16. Liability *

    1. I have read this and agree to the terms.

    1. I understand that I may be liable for the costs of any repair or replacement of equipment or materials resulting from damage beyond reasonable wear and tear through normal use, misuse, or theft while such equipment or materials are in my possession or control.  I understand the penalties that apply if equipment or materials are not returned on time.  I also indemnify Douglas Cable Access against any damage or liability incurred while using the equipment. 

18. Violations*

    1. I have read this and agree to the terms.

    2. I understand that violation of the terms of this statement is grounds for forfeiture of the right to use Douglas cable equipment and facilities or channel time. 

20. Handling*

    1. I have read this and agree to the terms.

    3. I have been instructed on how the access equipment I am borrowing is to be safely handled, including the storage and lifting of it in and out of my vehicle and/or dwelling. 

22. Digital Signature*

    Please Print Your Full Name As A Digital Signature

23. Date*
    Date

    All Equipment Loans are for Thirty (30) Days.  Please arrange for returns or fill out a new form within thirty days of the date on this form.  

25. Approval

    Once you fill out this form, you will get an approval from the Cable Access Coordinator with instructions on arranging the pickup of the equipment.  

Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field