Device Checkout Form
Modified on: Wed, 23 Feb 2022 11:05 AM
Last Name |
First Name |
Device Serial Number/s |
Technology Device Assignment Form
Employee Name: __________________________ Email Address: _______________________________
Device Type(s): ________________________________ Total Value of items assigned: $ __________________
This technology device agreement is to signify that the above-named employee is fully responsible for maintaining this device. Prior to device assignment, this form must be signed by the employee and the employee’s supervisor and returned to the Houston office. It is agreed that R and R Pipeline is not responsible for any loss of or damage to the device while in possession of the employee. If loss or damage occurs to the device following checkout, the employee must report this information to the IT Department immediately, and is responsible for the cost of repair or replacement of the device.
- I have attended/watched the Cyber Security Awareness Training provided by the R and R Pipeline IT department, and provided a copy of the course certificate to the R and R Pipeline HR Manager.
Employee Initials:
- I have read and agree to comply with the R and R Pipeline Cyber Security Policy and guidelines.
Employee Initials:
- I agree to accept full responsibility for this device and its appropriate work-related use for as long as it is assigned to me or in my possession. I further agree not to loan this device or my password to another employee, or allow its use by someone outside the organization.
Employee Initials:
- I agree to report any issues with device functionality to the R and R Pipeline IT department immediately for assessment and repair or replacement.
Employee Initials: _________
- I understand that failure to return the device and all associated hardware at the end of my employment with R and R Pipeline will result in the current replacement value of the device and associated hardware (keyboard, charger, storage case, etc.) being withheld from my final paycheck.
Employee Initials:
Last Name |
First Name |
Device Serial Number/s: |
Please record any damage or major wear/use marks on the device prior to checkout. Device Checkout Condition:
(Please list the condition of the device and any accessories -‐ power cord, keyboard, protective case and note any deficiencies.)
Item Serial Number (if applicable) Condition
iPad
Apple Lighting Charger
Zagg Keyboard
Zagg Cover
I understand and agree to these device use guidelines and authorize the Device Checkout section on this form to have the device assigned to me.
Assigned Date: Employee Signature:
Supervisor Signature:
