Chromebook Loan Form

Applicant Name(Required)

Student Name(Required)

(if different from Applicant)

Address(Required)

Street Address City State ZIP Code

Date of Application(Required)

Applicant Phone Number(Required)

Email(Required)

School/Program Name(Required)

Grade(Required)

(if applicable)

All Chromebooks and power cords must be returned to a member of the Education Department by the agreed upon date below. Chromebook renewals are also available upon request depending on demand. To request an extension, please email [email protected] at least 3 business days prior to your return date. Please include your reason for renewal and you will be issued a new contract with a new return date. Chromebooks are for education - related uses only and may not be used for unauthorized activities. Failure to return the Chromebook for any reason (including loss or theft) will result in a penalty of $13.33 per day ($400 maximum charge), which will be deducted automatically from FSP each month. If the Chromebook is returned in a damaged condition, the Department may repair the damage or replace the Chromebook, which costs will be deducted from FSP ($400 maximum charge).

Date of Return for this Contract(Required)

Signature of Applicant(Required)

Tribal ID Number(Required)

Date(Required)