Home-Based Employee Equipment Inventory Template

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Home-Based Employee Equipment Inventory
Clear Form
Employee Name: ____________________________________________________________
Telephone Number: _____________________ Pager Number: _______________________
Address: __________________________________________________________________
Work Unit: ______________________________ Manager: __________________________
Job Title:
______________________________
Computer Information:
Type of Computer: Desk Top (Stationary) or Mobile (Laptop or tablet)
Make: __________________________ Model: ________________________________
Serial Number: ___________________ DHR Inventory Number: ___________________
Type of Printer: ________________________ Serial Number: _____________________
Make: _______________________________ Model: ___________________________
Type of Fax Machine: ___________________ Serial Number: _____________________
Make: ______________________________ Model: ___________________________
Internet Provider: _________________________ Type of connection: DSL, Cable, Dial-up
Pager Information:
Type of pager: ___________________ Serial Number: ________________________
Radio Information:
Type of radio: ____________________ Serial Number: ________________________
Calling Card Number: ________________________________
Do you have any furniture in your home that was obtained from a DFCS office or state surplus
inventory? YES
NO
If yes, list type of furniture and state serial numbers on furniture:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Miscellaneous Information: _____________________________________________________
Employee Agreement:
I certify that I have the above equipment and other items in my
possession. Upon termination of my employment all state issued items must be returned to my
supervisor. If my office is moved from my home, the State will no longer reimburse me for
Internet charges. All state supplied items are to be used for business purposes only.
___________________________________
___________________________
Employee Signature
Date
Home-Based Employee Equipment Inventory
Clear Form
Employee Name: ____________________________________________________________
Telephone Number: _____________________ Pager Number: _______________________
Address: __________________________________________________________________
Work Unit: ______________________________ Manager: __________________________
Job Title:
______________________________
Computer Information:
Type of Computer: Desk Top (Stationary) or Mobile (Laptop or tablet)
Make: __________________________ Model: ________________________________
Serial Number: ___________________ DHR Inventory Number: ___________________
Type of Printer: ________________________ Serial Number: _____________________
Make: _______________________________ Model: ___________________________
Type of Fax Machine: ___________________ Serial Number: _____________________
Make: ______________________________ Model: ___________________________
Internet Provider: _________________________ Type of connection: DSL, Cable, Dial-up
Pager Information:
Type of pager: ___________________ Serial Number: ________________________
Radio Information:
Type of radio: ____________________ Serial Number: ________________________
Calling Card Number: ________________________________
Do you have any furniture in your home that was obtained from a DFCS office or state surplus
inventory? YES
NO
If yes, list type of furniture and state serial numbers on furniture:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Miscellaneous Information: _____________________________________________________
Employee Agreement:
I certify that I have the above equipment and other items in my
possession. Upon termination of my employment all state issued items must be returned to my
supervisor. If my office is moved from my home, the State will no longer reimburse me for
Internet charges. All state supplied items are to be used for business purposes only.
___________________________________
___________________________
Employee Signature
Date

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