Adaptive Technology Center for New Jersey Colleges
at The College of New Jersey
Department of Special Education
P. O. Box 7718 
Ewing, NJ 08628 		 Phone:  (609)771-2610
Fax:      (609)637-5172
Email:    atcenter@tcnj.edu
STUDENT LENDING AGREEMENT
1999 - 2000 Academic Year

Student Name: __________________    _____________________    Date: ________________
                    Last Name                                  First Name

College/University: ___________________________    Campus Phone: (        ) _____________
 
Campus Address: ____________________________________________________________
_________________________ ______ ______________ Email: ___________________
City State Zip Code
Home Address: ____________________________________________________________
__________________ ______ ______________ Home Phone: (        ): ______________
City State Zip Code
Student status: 
___ part time ___ full time
Credit status: 
___ freshman ___ sophomore
___ junior ___ senior
___ grad student
Disability: 
___ deaf/ hard of hearing  __ learning disability
___ blind/ visually impaired __ other
Are you registered with the NJ Commission for the Blind?    ___ Yes         ___ No
DVR? ___ Yes ___ No

Ethnicity (optional):
___ Caucasian  ___ African/ American ___ Native American
___ Hispanic/Latino  ___ Asian

Course(s) for which equipment will be used (course name and number):
____________________________________________________

Semester Beginning: _____________    Ending: _____________

Software Title: _______________________________________________  Platform:    Mac     Win

Hardware Title: _______________________________   Other Equipment:____________________

Disability Support Services Office - Name: ______________________________________________________________________________

Contact Person: ________________________________________  Phone: (       ) _____________

Email: _______________

Loan Agreement:

I, (print name)________________________ agree to be responsible for this equipment and return it in good condition on ______________, which is the end of the current academic semester. If the item I am borrowing is software, I agree to de-install it at the end of my loan period. I understand that copying software is illegal.

_________________________________________    _________________
(student signature)                                                          (date)

Funded by the Special Needs Grant Program of the New Jersey Commission on Higher Education