Item Description Cost + 10%

ACKNOWLEDGMENT OF EQUIPMENT ISSUE

I, ______, acknowledge that on this date I have been issued the following item(s) for my use while in the employ of Horizon Goodwill Industries., namely:

ITEM DESCRIPTION COST + 10%

______

I understand that it is my responsibility to maintain this item(s) in a condition of good cleanliness and repair and to return the item(s) to my employer upon request or at termination of my employment. I further understand and acknowledge that, should the item(s) placed in my care be lost, stolen, or damaged through my negligence, I will reimburse my employer for the cost of the item(s) plus a 10% handling charge, as stated above.

______Employee Name (Please Print) Date

______Employee Name (Please Sign)

______Manager Signature Date

D:\Docs\2018-01-08\02238117b94b253a1b6ef1926ba8ed69.doc Updated 1/07