NeuroTrial Form - NeurOptimal

LOANER CONTRACT APPLICATION

We do the best we can to ensure we have loaners in stock for this purpose, however loaner stock is limited, so we do count on our users to make arrangements for a timely return of the loaner to allow others in the community to have access to this program as needed.

ITEMS LOANED:*

Please select all applicable.

NeurOptimal® System & zAmp

EQUIPMENT SPECIFICATION:
The Loaned Tablet/Laptop will be the current or a recent previous generation of the hardware (Tablet/Laptop)

NAME*

First Last

PHONE NUMBER*

EMAIL:*

Pickup/Dropoff

I will pickup/dropoff the loaned system as agreed upon with internal contact.

SHIPPING ADDRESS:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PLEASE keep all original packaging to return the loaner equipment.

If packaging is accidentally discarded please obtain a proper shipping box from any FedEx shipping center. Failure to do so may result in a charge for any damages that occur to the equipment during shipping.

TIMELY RETURN & EQUIPMENT CONDITION:
At the end of the Term, or when this agreement is terminated, you must return the Equipment to us in full, using the return shipping labels included, in first class condition and with anything that belongs with it.

Return of all the loaner equipment and peripherals within 5 days of the loan termination date is expected. A daily rental fee of $35 may be incurred to the borrower in the event of a delayed return, if the delay is due to a lack of action on the borrowers part. If the loaned equipment is not returned within 30 days of term, or is returned in poor condition, without peripherals, not working, stolen, lost or damaged, or with any other issue which renders the system unusable for it’s purpose as decided by a Zengar Institute Inc. Customer Service Representative, you will be charged with the costs incurred to replace or repair the Loan equipment and/or any supplied peripherals as deemed fit by Zengar Institute Inc.

USE AND MAINTENANCE OF EQUIPMENT:
You must keep the Equipment in first class working order, repair and condition (fair wear and tear excepted), follow all the manufacturer’s instructions; and notify Zengar Institute, Inc. immediately if it is damaged, lost or destroyed. You must also keep the Equipment under your control. You must not sell or attempt to sell the Equipment, give possession of it, give any interest in it, or transfer or assign this agreement to any person, make any alteration or addition to the Equipment without our prior written consent.

LOAN TERMINATION DATE:
Your loan termination date will be provided to you in the email sent by your Zengar Institute Inc. contact.

SIGNATURE:*

Please enter your full name as your signature. Thank you.

DATE:*

Please enter today's date upon which you have agreed and signed this loaner form application.

NeuroTrial Application Form

LOANER CONTRACT APPLICATION