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                              uchc_logo.gif (10775 bytes)   REFERENCE # S Hit Counter         
                                                                                     OFFICE OF MATERIALS MANAGEMENT
                                                                                 "REMOVAL REQUEST FORM" - MM-2

MAIL ENTIRE PACKAGE TO:      Mike Stephens,  Materials Management and Surplus Property
                                                        Building 0J,   MC 6170,  Phone:   679-1956   Fax # 679-1964
NAME:    
BUILDING: FLOOR: ROOM  #:      TEL. #:      
DEPARTMENT:
MAIL CODE:  MC         E-MAIL: 
EQUIPMENT/ITEM TYPE:  Do Not Mix Equipment/Item Types On the Same Form!   Definitions of Equipment/Item Type: dotblink.gif (1956 bytes)
1.
      Movable Assets		 2.  
      Computer Software		 3.  
     PC & Electronic Materials		 4.  
      Fixed/Building Services Equipment		 Condition Codes: 
G=Good  F=Fair  P=Poor  S=Scrap

HC #

DESCRIPTION

 LOCATION

MODEL #

SERIAL #

CONDITION

SPECIAL INSTRUCTIONS: 

CODING:

FISCAL YR

LEDGER

ACCOUNT

SUBCODE

AMOUNT

AUTHORIZED SIGNATURE
 

Coding Must Be Provided!

________________________

IMPORTANT NOTICES TO DEPARTMENT HEAD:

  1. YOUR SIGNATURE ALSO CONFIRMS THAT ALL EQUIPMENT & ACCESSORIES USED WITH/OR HAVING CONTAINED RADIOACTIVE OR OTHER HAZARDOUS MATERIALS HAVE BEEN INSPECTED & APPROVED FOR SURPLUS, SHIPPING AND/OR STORAGE BY ENVIRONMENTAL & RADIATION SAFETY. FREON MUST BE REMOVED FROM ALL REFRIGERANT EQUIPMENT BEFORE DISPOSAL.
     

  2. YOUR SIGNATURE ALSO CONFIRMS THAT ALL ELECTRONIC STORAGE EQUIPMENT & DEVICES HAVE BEEN PROPERLY CLEANED OF INFORMATION ACCORDING TO UCHC HIPAA POLICIES.

THE EQUIPMENT / ITEMS REFERENCED ABOVE ARE HEREBY DESIGNATED AS EXCESS IN THIS DEPARTMENT. THE CUSTODY AND ACCOUNTABILTY OF THE EQUIPMENT / ITEMS WILL BE TRANSFERRED TO  SURPLUS MANAGEMENT - E.U.S. DIVISION OR THE FACILITIES MANAGEMENT DEPARTMENT.

AUTHORIZED SIGNATURES    (For Equipment/Items with a value of $5,000.00 or more, include signatures 4-6)
RELEASED BY:         ____________________________
5. VICE PRESIDENT FOR RESEARCH
   (Individual Equipment Over $10,000 Only)
 		 _______
DATE
___________________________
1.  DEPARTMENTAL PROPERTY COORDINATOR		 _______
DATE		 ____________________________
6. DEAN		 _______
DATE
___________________________
2. PRINCIPAL INVESTIGATOR
    (Equipment Purchased on Research Grants Only)		 _______
DATE		 RECEIVED BY:  
___________________________
3. DEPARTMENT HEAD		 _______
DATE		 ___________________________
1.  SURPLUS PROPERTY PROGRAM		 _______
DATE
___________________________
4. DIRECTOR OF  MATERIALS MANAGEMENT		 _______
DATE		 ____________________________
2.  FACILITIES MANAGEMENT		 _______
DATE

MM USE ONLY
RECEIVED BY:     
INITIALS: ________ 
TIME: ________  
DATE:  __________		 REQUEST IS: 
APPROVED:   
DENIED:       		SCHEDULED REMOVAL DATE: 

____________		 COMPLETED BY:   
INITIALS: ________ 
TIME: ________    
DATE:  __________

                               MAKE A COPY FOR YOUR FILE

IF YOU NEED ASSISTANCE COMPLETING THIS FORM, CALL 679-1956