First and Last Name Required Email Required Organization/Department Required Role Required Items Requested Required Please list the type and quantity of items needed Date that you will first need these items Required Date that you will return these items Required Select the box to indicate that you agree with the following statement: Required I agree that I am responsible for returning items in the same condition, allowing for normal wear and tear of items. If any items are lost or damaged, I will be responsible for the cost of replacement or repair. Leave this field blank