Device Charging Consent Form
Please complete this form to provide consent for charging your device and acknowledge associated risks. All fields are required.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Device Type
*
Please Select
Laptop
Tablet
Smartphone
Smartwatch
Other
Device Make & Model
*
Device Serial or Asset Number
*
Charging Location
*
Please Select
Main Office
Lobby
Conference Room
Tech Support Desk
Other
Date and Time Device Dropped Off
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Describe the Current Condition of Your Device
*
Additional Notes or Special Instructions
Submit Consent
Should be Empty: