Soil Probe Checkout Form
Soil Probe Checkout Form Cornell Cooperative Extension of Ulster County 232 Plaza Road, Kingston, NY 12401 Phone 845-340-3990, Fax 845-340-3993 Soil Probe Checkout Policy and Procedure Please print clearly and fill out the form below. Deposit: A deposit of $100 is required, to be provided with 2 checks made payable to CCEUC for $20 and $80, or by filling out the credit card form below. The deposit will be returned/destroyed upon return of soil probe to our office. Late fee: A $20 late fee will be charged if the probe is not returned within 2 weeks and the full amount will be charged after a month and you own the probe. Record of Soil Probe Checkout: Date: ___________ Probe # ______ Return date (within 2 weeks): _____________ Name: _____________________ Farm/Organization: _______________________________
Phone #: ____________________ Email address: ________________________________ Record of Deposit: Date: ______ Staff person: _____________ Method: check # ____ or credit card _____. Record of Probe Return: Date: ______ Staff person: _____________ How deposit returned (check one): Check returned ____ Credit card form destroyed _____ Borrower’s signature for return of deposit: _________________________ Date: _________ $100 Deposit for Use of Soil Probe - Credit Card Payment Authorization To be destroyed upon return of probe. If probe is not returned, form will be processed. Name as it appears on card: _____________________________________________ Street Address and Zip Code of Cardholder: _____________________________________ Card type: ____ VISA
____ MasterCard
Card Number: __________________________
Exp. Date: _____ Amt. to charge: $______ Signature (Required): _______________________
Phone #: ____________________ Email address: ________________________________ Record of Deposit: Date: ______ Staff person: _____________ Method: check # ____ or credit card _____. Record of Probe Return: Date: ______ Staff person: _____________ How deposit returned (check one): Check returned ____ Credit card form destroyed _____ Borrower’s signature for return of deposit: _________________________ Date: _________ $100 Deposit for Use of Soil Probe - Credit Card Payment Authorization To be destroyed upon return of probe. If probe is not returned, form will be processed. Name as it appears on card: _____________________________________________ Street Address and Zip Code of Cardholder: _____________________________________ Card type: ____ VISA
____ MasterCard
Card Number: __________________________
Exp. Date: _____ Amt. to charge: $______ Signature (Required): _______________________
