Information
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Prepared by
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Document No.
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Is this an Equipment Issue or Return
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Shop Issuing /Returning Equipment
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Issued / Returned on
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Location issued
Issued Equipment
ISSUING EQUIPMENT
Are you Issuing Equipment?
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Choose Equipment
- 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
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FPC TAG or Serial #'s ( if half-face or full-face respirator just put HF or FF ) ( MUST TAKE 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.
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Employee #
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Employee Name & Signature
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Name & Signature of Person Delivering Equipment
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Job Name /Location
RETURNINIG EQUIPMENT
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Are you Returning Equipment?
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Choose Equipment
- 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
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FPC TAG or Serial # ( if half-face or full-face respirator just put HF or FF ) ( MUST TAKE PHOTO)
Signatures
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Employee #
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Employee Signature
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Name & Signature of Person Receiving Equipment
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Job Name /Location
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Shop Person Name and Signature
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Location Received
