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Version 1.0
July 30, 2012
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Version 1.0
July 30, 2012
Manufacturer
Model
Item Description
Serial Number
Date
Loaned
Empl
Auth
Date
Returned
Empl
Auth
Version 1.0
July 30, 2012&
!"#$%#&'("#&)*(+(,$"&')*-&.(/0&/0#&1#2$*/-#,/3&.(/0&$&4)25&/)&/0#&6-2")5##&
Signed: _______________________________ Date: _____________
Complete upon return of all loaned equipment: I, _______________________ (print name) acknowledge receipt and inspection of the equipment listed above.
Authorized by (print name) __________________________ Signature: _________________________________Date: _________________
Agency/Department _________________ Employee (print name) __________________________ Empl ID#___________ Signature: ____________________ Date: ________
Tag
Number
This form tracks equipment/items that are in the temporary custody of a Santa Clara County employee. No equipment shall be taken to NON-County premises unless the
employee has completed a Telework Equipment Sign-Out Sheet.
All equipment in the employee's off-premises custody should be listed below. Additional equipment loans require an updated Equipment Sign-Out Sheet. Provide all information
requested, including date and initials of Employee and Authorizing individual in the “Loaned” column. Date and initial again in the “Returned” column when equipment is
returned.
All equipment loans are for the benefit of the organization and the convenience of the employee. In the event of termination of employment, the employee must return all
loaned equipment prior to receiving his or her final paycheck.
Telework Equipment Sign-Out Sheet
County of Santa Clara
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