Loaner Agreement Form

	Americas
	Hygiena 941 Avenida Acaso Camarillo, CA USA 93012 Tel: +1 805.388.8007 x.300 Fax: +1 805.388.5531 info@hygienausa.com Europe, Middle East, Africa & Asia Hygiena International Unit 11 WENTA Business Centre Colne Way, Watford, Hertfordshire WD24 7 ND. UK +44 (0)1923 818821 (tel) +44 (0)1923 818825 (fax) enquiries@hygiena.net

SystemSure PLUS™ Luminometer Loaner Agreement

Hygiena agrees to loan , (referred to as "Company" throughout the rest of this agreement) located at;

Address
Address 2
City
State
Zipcode	Country

one (1) SystemSURE PLUS™ luminometer for evaluation, including complimentary Ultrasnap ATP test devices. This Loaner Agreement is for a period of thirty (30) calendar days from the submission date.

When you are ready to return the instrument(s), please return to:
Hygiena
Attn: Evaluation Return
941 Avenida Acaso
Camarillo, CA 93012

If you plan on buying an instrument(s), contact your representative before returning the instrument(s).

In the event the SystemSURE PLUS™ is not returned within thirty (30) days from the effective date of this agreement or the SystemSURE PLUS™ is damaged or lost while in the possession of “Company Name”, then Hygiena will bill “Company Name” one thousand, one hundred and ninty-five dollars ($1195.00 U.S.), that being the purchase price of the instrument.

I AGREE TO THE ABOVE:
Authorized Person’s Name:
Email:
Date: 09/09/2010

Shipping Address of SystemSURE: check here if address is the same as above

Name
Address
Address 2
City
State
Zipcode	Country