AlPep Loaner Agreement AlPep LLC Equipment Loaner Agreement Form Name * Name First Name First Name Last Name Last Name Organization/Facility * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone * Email * Equipment Information Suction Machine WHISPER Fluid Collection System Collection Canister Needed? (Non-Returnable Item, Fees Apply) Not Needed ( I have my own)2000 cc ($30 Fee) Accessories Needed I have my own Connection Tube 6ft Connection Tube (Non-Returnable, $8 Fee applies) 10ft Connection Tube (Non-Returnable Item, $15 Fee applies) 5200mAH External Battery and Charger LOAN PERIOD LOAN START NEED DATE * Requested Loan Period * To be filled by AlPep LLC member Machine Serial Number / Inventory Number / Loaner Number Condition at the time of loan Used & Refurbished machineNew & Unused machine EXPECTED RETURN DATE Remarks / Instructions PURPOSE OF LOAN Delivery Method Pickup from AlPep LLC OfficeOn Site DemonstrationUSPS Ground Shipping (Flat Fee) Total Fees CC Payment (If Fees Apply) CC Payment (If Fees Apply) CC Payment (If Fees Apply) CC Payment (If Fees Apply) Month 123456789101112 CC Payment (If Fees Apply) Year 20262027202820292030203120322033203420352036 CC Payment (If Fees Apply) Terms of Loaner Agreement: <ul><li style="text-align: left;"><h3>I agree to return the machine/equipment in its original condition within the agreed loan period.</h3></li><li style="text-align: left;"><h3>Any damage or loss may be subject to charges.</h3></li><li style="text-align: left;"><h3>The Borrower agrees to use the Equipment solely for its intended purpose.</h3></li><li style="text-align: left;"><h3>The Borrower is responsible for maintaining the Equipment in good working condition.</h3></li><li style="text-align: left;"><h3>The Equipment must not be tampered with, modified, or repaired by unauthorized personnel.</h3></li><li style="text-align: left;"><h3>The Borrower is responsible for safely storing and handling the Equipment to prevent damage or loss.</h3></li></ul> By signing below, the Borrower agrees to all terms and conditions outlined in this agreement. * signature keyboard Clear Submit If you are human, leave this field blank.
