Student Pharmacist Check Out Form For Equipment Supplies

Today's Date:
Contact Name:
Phone Number:
UCSD Email Address
Organization/Course:
Event Date(s) needed:
Pick-Up Date:
Return Date:

  Requested Equipment: Quantity
1
2
3
4
5
6
7
8
9
10
Comments:

Please make an appointment to receive checked out equipments/products with:
Teah P. Stacks – Curriculum Assistant
p. 858.822.5508 f. 858.822.5624 email: tstacks@ucsd.edu
Should equipment(s) be damaged or stolen please notify any of the Faculty or Curriculum Assistant IMMEDIATELY.