Impaired Goggles Check-out Form

The goggles must be returned to the DCCCA, Inc./SAFE Office.
Return the goggles by certified parcel service, i.e., Federal Express, UPS, etc. Insure the contents for the replacement value of $1000.
The individual/organization named on this loan agreement is responsible for damage to and/or loss of the contents. While the contents are in your possession, it is recommended that they are insured for their replacement value of $1000.

Name Of Contact Person:(Required)

Organization Name:(Required)

Shipping Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

County Name:(Required)

Goggle Set Number:(Required)

Check-Out Date:(Required)

Return Date:

Send A Copy Of This Completed Form To Email Address: