Uniform Distribution Form
Name
First Name
Last Name
Date Property Received
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Date Form Signed
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Please fill out the items you received
Rows
Size
Number of Items Issued
Items Returned
Date Returned
Long Sleeve Black Uniform Shirt
13 XS
14 S
15 M
16 L
17 XL
18 2X
19 3X
20 4X
21 5X
22 6X
1
2
3
4
5
YES
NO
Long Sleeve White Uniform Shirt
13 XS
14 S
15 M
16 L
17 XL
18 2X
19 3X
20 4X
21 5X
22 6X
1
2
3
4
5
YES
NO
Short Sleeve Black Uniform Shirt
13 XS
14 S
15 M
16 L
17 XL
18 2X
19 3X
20 4X
21 5X
22 6X
1
2
3
4
5
YES
NO
Short Sleeve White Uniform Shirt
13 XS
14 S
15 M
16 L
17 XL
18 2X
19 3X
20 4X
21 5X
22 6X
1
2
3
4
5
YES
NO
Polo Shirt S/S
13 XS
14 S
15 M
16 L
17 XL
18 2X
19 3X
20 4X
21 5X
22 6X
1
2
3
4
5
YES
NO
Polo Shirt L/S
13 XS
14 S
15 M
16 L
17 XL
18 2X
19 3X
20 4X
21 5X
22 6X
1
2
3
4
5
YES
NO
Pants
13 XS
14 S
15 M
16 L
17 XL
18 2X
19 3X
20 4X
21 5X
22 6X
1
2
3
4
5
YES
NO
Light Jacket or Fleece
13 XS
14 S
15 M
16 L
17 XL
18 2X
19 3X
20 4X
21 5X
22 6X
1
2
3
4
5
YES
NO
Winter Jacket
13 XS
14 S
15 M
16 L
17 XL
18 2X
19 3X
20 4X
21 5X
22 6X
1
2
3
4
5
YES
NO
Winter Hat
13 XS
14 S
15 M
16 L
17 XL
18 2X
19 3X
20 4X
21 5X
22 6X
1
2
3
4
5
YES
NO
Black Tie
13 XS
14 S
15 M
16 L
17 XL
18 2X
19 3X
20 4X
21 5X
22 6X
1
2
3
4
5
YES
NO
Hard Hat
13 XS
14 S
15 M
16 L
17 XL
18 2X
19 3X
20 4X
21 5X
22 6X
1
2
3
4
5
YES
NO
Safety Vest
13 XS
14 S
15 M
16 L
17 XL
18 2X
19 3X
20 4X
21 5X
22 6X
1
2
3
4
5
YES
NO
Safety Glasses
13 XS
14 S
15 M
16 L
17 XL
18 2X
19 3X
20 4X
21 5X
22 6X
1
2
3
4
5
YES
NO
I understand that I have received the items listed above from ABC, Inc. The replacement value of each item is listed below. If I do not return all or some of these uniform items to ABC Services, Inc. upon termination of employment, ABC Company is authorized to deduct monies due to the company. If any uniform is returned to ABC Company damaged due to employee's negligence, ABC Company is authorized to deduct the appropriate amount from my next paycheck or any other monies due to me. I accept responsibility for the uniforms issued to me, including cleaning, upkeep, and minor repairs. Should the uniform become not serviceable at any time, I understand that I must contact my supervisor to exchange the item.
I understand the above
Item
Replacement Cost
Long Sleeve Shirt $46.50 Short Sleeve Shirt or Polo $42.50 Light Jacket, Fleece or Pants $45.00 Winter Jacket $65.00 Pants 45.00 Winter Hat $15.00 Hard Hat $20.00 Safety Vest $25.00 Safety Glasses $22.00 Black Tie $25.00
Signature
Submit
Should be Empty: