Assistive Technology Loan Agreement Student Support Office of ACCESSibility Information for Current Students Assistive Technology Loan Agreement Assistive Technology Loan Agreement 猛男情报局 Please fill in a valid value for all required fields Please ensure all values are in a proper format. Are you sure you want to leave this form and resume later? Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form. Save and Resume Later Save and get link You must upload one of the following file types for the selected field: There was an error displaying the form. Please copy and paste the embed code again. Apply Discount You saved with code Submit Form Submitting Validating There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue. Please check the field: Fields First Name * First Name* Last Name* CWID * 猛男情报局 Email * Telephone (Cell) * Mailing Address* Address Line 1 Address Line 2 City 听 Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State ZIP Code Campus* Dobbs Ferry Manhattan Bronx Distance Learning Type of Assistive Technology you are requesting* SMART Pen Recording Device FM System C-Pen Reader Spell checker Other: Other Value Checking out Assistive Technology for.... * Fall Spring Summer Year I would like to receive my Assistive Technology.... in-person at campus by mail Loan Agreement Students should inspect all equipment for any defects or other objections to the equipment before acceptance. If the student accepts delivery of the equipment, the student is presumed to have accepted the equipment in good condition and repair.No other individual or entity may use the equipment for the entire time in which the equipment is on loan to the student. Equipment is not to be used for anything other than its intended purpose, as an academic accommodation, during the instructional period.We reserve the right to immediately terminate this agreement and confiscate the equipment at any time.Great care must be taken in preserving the equipment in good condition and any damage to said equipment will be reported in writing to 猛男情报局 ACCESS within 48 hours of occurrence. Students shall not attempt to make any repairs without the express permission of the 猛男情报局 ACCESS.The student assumes financial responsibility for lost or damaged equipment. If the equipment is not returned by the end of the student鈥檚 final semester, returned in damaged condition, or lost, the student鈥檚 account will show an outstanding balance resulting in the charge for the equipment.Non-payment will result in a hold being placed on the account which could affect the student鈥檚 inability to access grades, register, and graduate. I understand that the cost to replace a lost, stolen, broken, or damaged SmartPen is $200.00. I understand the cost to replace a lost, stolen, broken, or damaged recording device is $50.00.听 I understand the cost to replace a lost, stolen, broken, or damaged FM hearing device is $1,000.00. I understand the cost to replace a lost, stolen, broken, or damaged C-Pen Reader is $300.00 I understand the cost to replace a lost, stolen, broken, or damaged Spell Checking device is $50.00.听 The cost of replacing the technology I am checking out is.... I Acknowledge The Above Agreement* I Acknowledge The Above Agreement Date* https://www.formstack.com/forms/images/2/calendar.png Month 01 02 03 04 05 06 07 08 09 10 11 12 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 Signature [clear] Use your mouse or finger to draw your signature above Device Serial Number Date equipment was picked up https://www.formstack.com/forms/images/2/calendar.png Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 Date equipment was returned https://www.formstack.com/forms/images/2/calendar.png Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 Notes - Copy Previous鈫 Next鈫 Enter your save and resume password Cancel Confirm