We certify that the records listed in this Request and Authorization are no longer of any value for official or administrative purposes and that they are eligible for disposal in accordance with the Retention and Disposition Schedule for University Records (Attachment 1 to University Procedure 2D:03:01A). We therefore request and authorize their disposal in accordance with this procedure.

Signatureof Requestor _____________________________________________________  Date ____________

Signature of Approving Authority _____________________________________________  Date ____________

Approval by Appropriate Vice President/Provost ________________________________  Date ____________

Endorsement of University Records Officer:

______ Recommend Disposal   _______ Do Not Recommend Disposal

Signature of University Records Officer _______________________________________

Indicate below the name of record series, time span, size of box, current location of records, and retention requirements; use additional lines if necessary.