Town of Gray, Maine
GCTV-2 EQUIPMENT LOAN FORM
NAME:_____________________________ PROJECT NAME: _____________________________
ADDRESS: _________________________________________ PHONE: _________________
DATE EQUIPMENT SIGNED OUT: _________________ ACKNOWLEDGED By: ______________
(FOR SPC-TV)
DATE EQUIPMENT TO BE RETURNED:_______________________________________________
EQUIPMENT SIGNED OUT:
CAMCORDER KIT-INCLUDES THE FOLLOWING ITEMS - INDICATE QUANTITY BESIDE ITEM:
MANUFACTURER_________________ MODEL NO. ______________ SERIAL NO.___________
___ CAMERA
___ BATTERY(S)
___ A/C ADAPTOR
___ CABLE(S)
___ WIDE ANGLE LENS
___ CAMERA MANUAL
___ CARRYING CASE
WIRELESS MICROPHONE KIT TO INCLUDE:
___ TRANSMITTER
___ RECEIVER
___ MICROPHONE
___ RECEIVER TO CAMCORDER CABLE
___ 2 PLASTIC CLIPS
OTHER MICROPHONES:
___ HAND HELD MICROPHONE
___ UNIDIRECTIONAL MICROPHONE
___ MICROPHONE CABLE(S)
___ MICROPHONE ADAPTOR CABLE
OTHER ITEMS:
___ TRIPOD(S)
___ TAPES(S)
___ OTHER (EXTENSION CORDS,CABLES, HEADSETS, ETC.__________________________
I DO HEREBY ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE RULES AND REGULATIONS FOR USING GCTV-2 EQUIPMENT AS OUTLINED IN OUR CURRENT POLICY MANUAL AND THAT I AGREE TO THE TERMS SET FORWARD THEREIN.
SIGNED:________________________________ DATE: ____________________________
EQUIPMENT RETURNED IN SATISFACTORY CONDITION: __________________ ___________
SIGNED IN BY____________________ DATE ______________________________________
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