Equipment Delivery / Return Form

Title Page

ISSUING or RETURNING EQUIPMENT

Are you Issuing or Returning Equipment?
Choose Equipment to Issue
- Anchors $25 - $35
- Harness $45 - $65
- Lanyard $45 - $65
- YoYo - $60 - $350
- Lifeline - $100 - $200
- Respirator - $20 - $120
- First Aid Kit $25
- Rope Grabs - $35 - $85
- Parapet Anchor $350
- Beam Anchor - $85 - $150
FPC TAG or Serial #'s ( if half-face or Full-face respirator just put HF or FF ) ( Must take a photo of each equipment)

Signatures - By signing , I acknowledge that I received the equipment that is listed above. I understand that this equipment is my responsibility to take care of it. If I lose it, it gets destroyed , stolen or I don't return at the end of my employment; I will be responsible for the replacement cost. I acknowledge and authorize to get it deducted from my last pay check. Al firmar, reconozco que he recibido el equipo que se indica arriba. Entiendo que es mi responsabilidad cuidar de este equipo. Si lo pierdo, me lo destruyen, me lo roban o no lo devuelvo al final de mi empleo; seré responsable del costo de reemplazo. Reconozco y autorizo a que se me descuente de mi último cheque de pago.

Employee #
Employee Name & Signature
Person Delivering Equipment - Name & Signature
Job Name and Location
Complete & Ready to Send
What Equipment is being returned
- Anchors $25 - $35
- Harness $45 - $65
- Lanyard $45 - $65
- YoYo - $60 - $350
- Lifeline - $100 - $200
- Respirator - $20 - $120
- First Aid Kit $25
- Rope Grabs - $35 - $85
- Parapet Anchor $350
- Beam Anchor - $85 - $150
FPC TAG or Serial #'s ( if half-face or Full-face respirator just put HF or FF ) ( Must take a photo of each equipment)
Employee #
Employee Name and Signature
Person reciveing Equipment - Name & Signature
Job Name & Location
Shop person receiving Name & Signature
Location received
Complete & Ready to Send