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Impaired Vision Goggles Checkout Form

1. The goggles must be returned to the Kansas Traffic Safety Resource Office within 3 business days after the event.

2. Return the goggles with the pre-paid USP label.

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.

4. Please make sure all goggles are put back in their respective protective bags. Each kit has 6 different goggles.

 

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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