NHS Delivery Note

Date	______________________	day of _________________________ 200_____

Supplier  ____________________________________________________________

Form of Indemnity Reference Number _____________________________________

Authority _________________________________________________

This NHS Delivery Note specifies the Equipment provided under the NHS Form of Indemnity with the reference number shown above. 
Model/make  _________________________________________________
Serial Number  _______________________________________________
Value  ______________________________________________________
Description  __________________________________________________
Purpose  _____________________________________________________

Form of Indemnity A
Period of loan:
[		] years and [	] months commencing on [       ] day of [      ] 200[  ]
The trial/testing to be undertaken by the Authority (if any)  _____________ 
___________________________________________________________
Premises at which the Equipment will be kept:
_____________________________________________________________
_____________________________________________________________

The Authority acknowledges receipt of the Equipment detailed above on the terms of the Form of Indemnity detailed above:
SIGNED on behalf of the Authority _______________________________
The Supplier confirms delivery of the Equipment detailed above to the Authority for loan on the terms of the Form of Indemnity detailed above:-

SIGNED on behalf of the Supplier  ________________________________ 
Form of Indemnity B
The Authority acknowledges receipt of the Goods detailed above from the Supplier on the terms of the Form of Indemnity detailed above:-
SIGNED on behalf of the Authority ________________________________
The Supplier confirms delivery of the Goods detailed above and transfer of the legal and equitable title to those Goods to the Authority as from the date hereof on the terms of the Form of Indemnity detailed above:-

SIGNED on behalf of the Supplier  ________________________________ 

-----------------------------------------------------------------------------------------------------------------

Form of Indemnity A – collection at the end of the loan period

The Authority confirms collection by the Supplier of the Equipment detailed above:

SIGNED on behalf of the Authority ________________________________

The Supplier acknowledges receipt of the Equipment detailed above:

SIGNED on behalf of the Supplier  ________________________________

DATE:  ________________________________________