Impaired Goggles Check-out Form

  1. The goggles must be returned to the DCCCA, Inc./SAFE Office.
  2. Return the goggles by certified parcel service, i.e., Federal Express, UPS, etc. Insure the contents for the replacement value of $1000.
  3. 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.

Your Contact Information

Shipping Address:(Required)
Check-Out Date:(Required)
Return Date: