Spot Vision Screener Request Form

1. Email Address? *This question is required. This question requires a valid email address.

3. Individual Requesting Use of Device? *This question is required.

4. Check Out Date? (MM/DD/YYYY) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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5. Return Date? (MM/DD/YYYY)

(TWO WEEKS MAXIMUM UNLESS OTHER ARRANGEMENT MADE PRIOR TO CHECK OUT) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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6. Individual Picking Up Device From NWESD 189?

(SIGNATURE REQUIRED UPON PICKUP)

7. Individual Has Received Proper Training in the Use of Device? *This question is required.

Please submit your Spot Vision Screener Request Form. If you do not receive email confirmation within 24 hours please call (360) 299-4073.