You must have JavaScript enabled to use this form. By signing this agreement, you are acknowledging that you have rented the Fuji GFX 50S camera from the Photography Program of the Art Department of CSUSB. You are responsible for the camera, lens, and any related accessories. If lost, stolen, or damaged you are responsible for the replacement value – $15,399.54. Lost lens caps are subject to a $30 fee. Please fill out the student information section below. How-to Tutorial Video Student Information Name Address Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Phone Number Student ID # Email Address Class Term Instructor Date Requesting to pick up equipment Monday 10:30am 11am 11:30am 12pm 12:30pm 1pm 1:30pm 2pm 2:30pm 3pm 3:30pm Wednesday 12:30pm 1pm 1:30pm 2pm 2:30pm 4pm 3pm 4:30pm Thursday 12:45pm 1pm 1:30pm 2pm 2:30pm 3pm 3:30pm 4pm 4:30pm 5pm 5:15pm Friday 10am 10:30am 11am 11:30am 12pm 12:30pm 1pm 1:30pm 2pm 2:30pm 3pm 3:30pm 4pm 4:30pm Student Signature Sign above Date Signed Camera type: Fuji GFX 50S Select the items you wish to request Fuji GFX 50S Body (valued at $6,449) GFX 50S Grip (valued at $200) GFX 50S Tilt Adapter View Finder (valued at $699) Fuji GF 23MM F4 lens (valued at $2,889.96) Tether Pro USB Cable (valued at $35.59 each) Fuji GF 32 - 64MM F4 Lens (valued at $2,149) Fuji GF 120MM F4 Macro Lens (valued at $2,599) Three Rechargeable Batteries and Charger (valued at $113.05 each) FUJI RR-90 REMOTE RELEASE (valued at $31.99 each)