NAME:

CAMPUS ADDRESS:

CAMPUS PHONE:

I, _________________________________, accept full responsibility in event of any loss or damage resulting from my negligence to the school instrument listed below. I agree to keep the instrument in good playing condition and to pay for any repairs made necessary by misuse, negligence, or carelessness. I will present the instrument for inspection promptly when called for and will return in on or before May 11, 2002.



Instrument: _______________________ Make: _________________________

Serial Number: ____________________

Accessories listed here are understood to be included in this agreement:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________



Date assigned: ____________________ Date returned: __________________