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EQUIPMENT CHECKOUT AND RESPONSIBILITY FORM

Company Name

Address Address

City, State Postal Code

Phone Phone Number CHECKOUT DATE:

Employee Name (Please print)

Department / Supervisor

Equipment to be checked out to Employee by Company. Included Software and Licenses (attach additional lists if necessary). Replacement Value of all Equipment and Software.

Please list any defects, damage or problems with any equipment to be checked out to employee:

Sensitive and Confidential Information

All employees, contractors or staff members have the obligation to protect sensitive and confidential information that may be contained on any equipment that they check out or that may be in their possession. All mobile computing users who make use of wireless networks must use VPN encryption protocols to send or transmit sensitive or confidential information in any form. No employee, contractor or staff should ever access an internal company network resource without being secured by VPN encryption protocols, as all Company internal networks, network resources or other internal assets shall be deemed sensitive and confidential information.

The Company also reserves the right to pursue legal remedy for damages incurred as a result of an employee's violation. For additional information, consult the Company Wireless Network and Mobile Computing Policy. Certain illegal activities will require that Company immediately notify or comply with the proper authorities upon discovery.

The Company reserves the right to examine any user's equipment, whether personally owned or Company owned, that accesses Company Email Account(s), Web Logs, Chat Logs, Networks, Access Points or any other information passed through Company resources or Network, or stored on Company computers, at any time and without prior notice. Company is not responsible for users who display, store, or otherwise transmit any personal information such as passwords, banking information, credit card numbers, social security or tax ID numbers, or make use of Internet "passports" or "wallets" while using Company equipment. Company shall not be held liable for damages resulting from any loss of such information, abuse by other parties, or any consequential loss of personal property or injury resulting from the storage or loss of such information. The practices described in this Equipment Checkout and Responsibility Form are current as of Current Date.

Company reserves the right to modify or amend this policy at any time.

Effective Date: Current Date

I hereby declare that I have read and fully understand my duties and obligations set forth in the above Equipment Checkout and Responsibility Form for Company Name, and I will uphold these duties and obligations at all times. EXECUTED as of the date first written above. Signature: Date when the contact was signed.

Employee Initials