SECTION 1 – Equipment
The following equipment has been borrowed from the Virginia Department of Forestry (VDOF):
Item	Quantity Borrowed	Property Number / Item Number	Comments
1.	Fire Shirt
2.	Fire Pants
3.	Brush Coat
4.	Nomex Coveralls
5.	Fire Helmet
6.	Fire Shelter
7.	Web Gear
8.	Nomex Neck Protector
9.	Gloves
10.	Canteen
11.	Head Lamp
12.	Planting Bar
13.	Seedling Bag
14.
15.
16.
SECTION 2 – Agreement
I agree to return the borrowed equipment listed above promptly upon completion of use. For firefighting personal protective equipment, in the event that I cease wildland fire suppression employment for the Virginia Department of Forestry (VDOF) or do not renew my fitness test as required as a condition of wildland fire suppression employment for VDOF, I will promptly return all personal protective equipment. If all equipment is not returned, I hereby agree to pay VDOF the amount equal to the replacement cost for all equipment not returned. It is further understood that if the equipment is damaged, beyond normal wear and tear, that I will reimburse VDOF for replacement costs.
Borrower Name (Print)	Borrower Signature	Date
Address:
City:	State:	Zip:
E-mail:	Phone:
SECTION 3 – Issued By
VDOF Employee Name (Print)	VDOF Employee Signature	Date
Comments:
SECTION 4 – Return Verification
I certify that the equipment listed above was returned.	Equipment Condition:	Good	Poor
VDOF Employee Name (Print)	VDOF Employee Signature	Date
Comments: