WAIVER OF LIABILITY

This is to Certify that ____________________ has returned in __________ condition the

equipment issued to him/her. Identified as follows:

NAME OF EQUIPMENT

DATE ISSUED

SERIES/MODEL NO.

PARAPHERNALIA

The Company hereby waives any and all liability and obligations of the employee in relation
only to the equipment issued and identified in the table above.

Return date:

Returned to:

Signed: