Device Loan Request Form

Thank you for submitting your request for Oklahoma ABLE Tech's device loan program. Please allow 1-2 business days for your request to be reviewed by an ABLE Tech staff member. Should the device you requested not be available for loan, you will be added to the wait list to receive the equipment.


Questions? Contact ABLE Tech at 888.885.5588 or abletech@okstate.edu


* indicates REQUIRED field


Person requesting the equipment


Name*
Please select your preferred method of delivery*

Do NOT use a P.O. Box number for the shipping address. A street reference is necessary. If delivery is to a large facility, please specify a department name and/or room number. A return shipping label will be provided free of charge.

Please ship to the following person if the address is different than above.

Name

DEVICE REQUESTED

I am a person with a disability, and I am a parent.
Name

PERSON BORROWING THE DEVICE

FEES
At this time, there are no rental fees to borrow Oklahoma ABLE Tech's assistive technology devices. However, late fees may be charged for any device not returned by the due date. Late fees may be assessed at a rate of $25 per week. Failure to return a device by the due date will subject you to all applicable legal action.


The person who is the responsible party for this loan should agree with the following statements and sign.


RELEASE OF LIABILITY
I agree to indemnify and hold harmless Oklahoma ABLE Tech and any and all employees, agent or representatives of same, from damages to property or injuries (including death) to myself, and/or any other person, and any other losses, damages, expenses, claims, demands, suits and actions by any party against Oklahoma ABLE Tech and any and all employees, agent or representatives of same, in connection with device loan(s) from Oklahoma ABLE Tech.

RESPONSIBILITY AND LIABILITY


I understand and agree that I am responsible for the proper handling, storage, use, care, maintenance, and return of the device(s), component(s), or accessory(ies) loaned to me hereunder.

In the event that I lose or there is a malfunction of device(s), component(s), or accessory(ies), I shall immediately notify Oklahoma ABLE Tech at 888.885.5588.

In the event of a theft of the device(s), component(s) or accessory(ies), I will report the theft to the local law enforcement agency and provide a copy of that report to Oklahoma ABLE Tech.

I shall not pledge, assign, transfer, or otherwise give any interest in and to the device(s), component(s), and accessory(ies) to any third party not listed on the loan request form.

I understand it is illegal to copy or distribute any proprietary software or hardware loaned through Oklahoma ABLE Tech. Upon completion of the loan, if I have installed such software on my computer, I shall remove said software.

In the sole discretion of Oklahoma ABLE Tech, my ability to further participate in any such programs or grants or loans from the Oklahoma ABLE Tech and all of its related programs may be suspended for a period of time or indefinitely for failure to abide by the Loan Request Form and all of its obligations.