I understand that I am personally and financially responsible for the equipment listed on this form, and that it will be used solely by me for the above program to be cablecasted on "The Authority" Public Access Channel and that it will be returned in the same condition as issued. I understand that failure to return the equipment by the date and time specified above may result in actions by The Authority ranging from written warnings, to suspension and possible revocation of my Public Access privileges. In addition, I may be responsible for the cost of repair or replacement should the equipment be lost or damaged while it is in my care.

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Signature Date

Checked out by (The Authority employee print name):____________________

Checked in by (The Authority employee signature):______________________

Date:______________________ Time:_____________________

Checked out by (The Authority employee print name):____________________

Checked in by (The Authority employee signature):______________________

Date: ____________________ Time:______________________