Title Page
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Site conducted
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Name of Recipient
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Department
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Supervisor
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New Equipment Issued
- Body Harness
- SRL
- Lanyard
- Wedge/Toggle Anchor
- Other
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Harness Asset Tag Number
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Harness Size
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Harness Condition
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SRL Asset Tag Number
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SRL Condition
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Lanyard Asset Tag Number
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Lanyard Condition
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Anchor Asset Tag Number
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Anchor Condition
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Equipment Type
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Equipment Asset Tag Number
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Equipment Manufacturer
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Equipment Model #
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Equipment Lot #
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Equipment Serial #
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By signing this form, I hereby acknowledge the receipt of the above listed equipment. I will immediately contact FINFROCK Safety to report any lost or damaged equipment, and to request new equipment. All equipment must be returned in its original condition, with all parts and pieces present, upon termination of employment or job reassignment to a position that does not require the equipment.
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Recipient Signature
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Date of Receipt
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Person Issuing Equipment
