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Impaired Vision Goggles Checkout Form

1. The goggles must be returned to the Kansas Traffic Safety Resource Office.
2. Return the goggles by certified parcel service, i.e., Federal Express, UPS, etc. Insure the contents for the replacement value of $900.00
3. The individual/organization named on this loan agreement is responsible for damage to and/or loss of the contents. While the contents are in your possession, it is recommended that they are insured for their replacement value of $900.

Your Contact Information

I have read this loan agreement and understand the requirements outlined. If there are any changes in my/the organization's plans, I will notify the Kansas Traffic Safety Resource Office immediately. By typing your name in the space provided, and entering today's date, you are signing this agreement.

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