Multi-user electric breast pump loan agreementMulti-User Electric Breast Pump Loan Agreement • April 21st, 2015
• I understand that this breast pump is the property of the WIC program and is on loan to me. I will protect the pump from theft or loss by keeping it in a secure location at all times. I will not smoke around the pump. I will not sell the pump, give it away, or let anyone else use it.
Multi-User Electric Breast Pump Loan AgreementMulti-User Electric Breast Pump Loan Agreement • September 7th, 2018
District: Clinic: Loan Terms and ConditionsRead each statement, initial, and sign below: I have received instruction on the assembly, use, and cleaning of the pump. I understand how to use and clean the pump, and how to safely store my breast milk. Further, I agree to use the pump according to the instructions for assembly, use, and cleaning. I understand that this pump is the property of the Georgia WIC Program and is on loan to me. Therefore, I will not sell the pump, give it away, or let anyone else use it. I will keep the pump in a secure location at all times; and will report any loss or theft of the pump to the WIC Clinic. I will call my WIC Clinic if the pump is not working properly, if parts break, or it is otherwise damaged. I will not smoke around the pump. I agree that the pump I have been loaned by the WIC Clinic is clean and in good working condition. I will return the pump if I no longer need the pump; if I leave the state of Georgia; if I no longer maintain
ContractMulti-User Electric Breast Pump Loan Agreement • November 16th, 2015
Multi-User Electric Breast Pump Loan AgreementMulti-User Electric Breast Pump Loan Agreement • September 7th, 2018
District: Clinic: Loan Terms and ConditionsRead each statement, initial, and sign below: I have received instruction on the assembly, use, and cleaning of the pump. I understand how to use and clean the pump, and how to safely store my breast milk. Further, I agree to use the pump according to the instructions for assembly, use, and cleaning. I understand that this pump is the property of the Georgia WIC Program and is on loan to me. Therefore, I will not sell the pump, give it away, or let anyone else use it. I will keep the pump in a secure location at all times; and will report any loss or theft of the pump to the WIC Clinic. I will call my WIC Clinic if the pump is not working properly, if parts break, or it is otherwise damaged. I will not smoke around the pump. I agree that the pump I have been loaned by the WIC Clinic is clean and in good working condition. I will return the pump if I no longer need the pump; if I leave the state of Georgia; if I no longer maintain
ContractMulti-User Electric Breast Pump Loan Agreement • November 16th, 2015
Georgia Special Supplemental Nutrition Program for Women Infants and Children (WIC) Multi-User Electric Breast Pump Loan AgreementMulti-User Electric Breast Pump Loan Agreement • January 19th, 2021
District: Clinic: Loan Terms and ConditionsRead each statement, initial, and sign below:⎯ I have received instruction on the assembly, use, and cleaning of the pump. I understand how to use and clean the pump, and how to safely store my breast milk. Further, I agree to use the pump according to the instructions for assembly, use, and cleaning.⎯ I understand that this pump is the property of the Georgia WIC Program and is on loan to me. Therefore, I will not sell the pump, give it away, or let anyone else use it.⎯ I will keep the pump in a secure location at all times; and will report any loss or theft of the pump to the WIC Clinic.⎯ I will call my WIC Clinic if the pump is not working properly, if parts break, or it is otherwise damaged.⎯ I will not smoke around the pump.⎯ I agree that the pump I have been loaned by the WIC Clinic is clean and in good working condition.⎯ I will return the pump if I no longer need the pump; if I leave the state of Georgia; if I no longer maintain
