Temporary Removal of Equipment from UTHSC-H Premises Permit

1. The laptop pool is administered by Network Services at UCT 1100.
2. Prior to completing this form,click here to check on the availability of a laptop.
3. This form cannot be e-mailed directly because of required signatures. However, you may fill out the form, print it and get appropriate signatures.
4. Department Heads will be responsible for signing the removal form. NOTE: The department will be responsible for if damaged, lost or stolen.
5. After the department approves the removal form, the client will return this form to NS and pick up the laptop at UCT 1100, 2:00-4:00 pm, Mon-Fri..  Employees must bring their UT badge for identification.  Employees will be allowed up to two weeks on checkout.
6. The client is responsible for returning the laptop to UCT 1100, 9:00-11:00 am, M W T F  by the due date. NOTE: Not open on Tues mornings.
7. NS will check the laptop in and re-image (restore the computer to standard defaults). Employees should remove all data before returning the laptop.  Network Services will not be responsible for data  left on the laptop.  If there is any damage to the laptop, NS will report this to the Department Head. 

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The Undersigned certifies that:

1. The purpose listed above constitutes official business of The University of Texas Health Science Center at Houston.

2. The equipment removed will be taken to: 

3. Name, title and signature of person responsible for equipment while it is removed from the premises:

Name:
Title:

Signature_____________________________________________________

4. Date upon which equipment will first be removed from the premises:

5. Date by which equipment removed will be returned to the premises: 

Date of Request: Department Head Signature: __________________________________