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Please Print This Form and Submit HARD COPY (Original Signatures Are Required)

Employee’s Mailing Address:______________________________________________

Employee’s Identification No.:(In U.S use Social Security No.)________________________

Company Location:____________________________________________________________

Description of computer package to be purchased:___________________________________

Computer Package Price:

Less down payment;
(minimum 10% of total):

Amount of Loan:

The Employee hereby requests a loan of the above amount through the Tyco Employee Purchase Program.

Employee’s Signature:

Date:

Computer Purchase Coordinator:

Signature:

Date: