Loaner Request Form
First Name
Last Name
Principal Investigator
Shipping Address
Reason for Loaned Devices
Help Desk Ticket Number
Loaner Agreement Blackrock Microsystems, hereafter "Blackrock", and the institution named in the Institution field of this form, represented by the individual named in the First and Last Name fields of this form, hereafter "Customer", declare they are in agreement to the terms that follow in this agreement.
This agreement is for the purpose of the lending of Blackrock owned equipment for one month from the date of shipment of the equipment to the customer. All loaned items from Blackrock to the customers is hereafter referred to as "equipment" or "the equipment".
- Blackrock is and will be the owner of the equipment; it is on loan to the customer for this period.
- This equipment is being loaned at Blackrock's discretion.
1. General Conditions
- Customer will not rent, sell or dispose of the equipment in any other way.
- Customer is responsible to take good care of the equipment to maintain it so that it remains in a representable and functional state.
- Customer is forbidden to use the equipment for activities that could harm Blackrock's professional and/or commercial activities or its corporate image.
- Customer is not allowed to make any changes in the configuration of the equipment without prior permission from Blackrock.
- Customer is expected to document equipment damaged in shipment upon receipt and to notify Blackrock within 48 hours of receipt of violations of this.
2. Theft and Damages
- Customer has to take care of prevention of damaging, theft, or loss of the equipment.
- In case of damages or theft, Customer is obliged to report this as soon as possible, yet always within 48 hours, to Blackrock.
- Customer can be held liable for damages to the equipment because of culpable negligence or laches.
3. Period of Use
- Customer has to return the equipment within the period agreed upon, at the first request, and in full to Blackrock. In neglect of this, Customer is obligated to pay Blackrock the residual book value of the equipment.
- By checking the box below and entering their name into the E-Signature field, Customer declares to have read the agreement and acknowledges the responsibilities and consequences coming forth from this agreement.
Acknowledgement By checking this box, I acknowledge that I have read and agree to the agreement above.


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