HTML Preview Equipment Release Form page number 1.
Dedham TV
95 Eastern Ave. Dedham, MA 02026
781-326-2107 • dedhamtv.org
EQUIPMENT RELEASE FORM
Type of application request: (circle one) INDIVIDUAL/BUSINESS/ORGANIZATION
Name: ________________________________________
Address: (Street) _________________________________ (City/Town) __________________________
State: __________________________________________ (Zip Code) ___________________________
Phone: ________________________________ Fax: _________________________________________
E-Mail: ________________________________ Website: _____________________________________
Equipment Requested:
TYPE OF EQUIPMENT
HOW MANY?
Notes regarding the equipment:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Date removed: (m/d/y)______________________ Return date: (m/d/y) ________________________
By signing below, I acknowledge and understand the DTV equipment policy as outlined by the staff member who allowed
this equipment out of the studio. I will return this equipment on or before the due date listed above, and additionally, I am
responsible for replacing ANY and ALL damaged, lost, or otherwise compromised goods that I have rented from DTV.
Staff Signature: ____________________________ Assignee Signature: __________________________