UNIVERSITY OF CALIFORNIA, IRVINE
EQUIPMENT ASSIGNMENT FOR UNIVERSITY PROPERTY LEAVING THE CAMPUS

		Agreement No.		
				
Date				
Assigned By Department				
Department User		Fac/Staff	Telephone No.		
Equipment Description		UCI Property No.		
Manufacturer Of Equipment		Serial No.		Value	$	
Period of Use		to				
The equipment will be located at		during the period indicated.	

The equipment described above is assigned to the user for the purpose of instruction, demonstration, research, or general University support, directly associated with an authorized University activity.  The user’s department agrees to assume financial responsibility for loss or damage to the equipment while the assignment is in effect.   By signing this agreement the Department Chair/Business Officer attests to his/her understanding of the above requirements.  

The user further attests that the equipment will be used for the purposes described above and understands that he/she will be personally responsible for any loss or damage as a result of any intentional misuse or misappropriation of said equipment by user. 

THE EQUIPMENT IS SUBJECT TO RETURN ON DEMAND

Signed	
	Date		
	Department Chair/Business Officer			
Signed	
	Date		
	User			
Signed	
	Date		
	Materiel Manager			

MATERIEL MANAGER				
				
The equipment described on Agreement Number		has been returned to		

		Signed		
				
			Department Chair/Business Officer	

Instructions:

1.	Complete form in triplicate.
2.	Send all copies to Equipment Management
3.	An approved copy will be returned to your department.
4.	When equipment is returned - Remove lower portion - Send to Equipment Management

Retention:  3 years beyond expiration