SURPLUS REQUEST FORM
Request ID:

Contact:
Terry Byron
Request Date:
//
Phone:
/-
Request Status:
Submitted
Email:
tbyron@ncsuedu
Department:
 College of Sciences - Dean
Surplus Action:
Pick-Up
Pick Up Location: A
Comments:
In room  Room locked Please call ahead of time Receptionist at  can provide entry or Terry Byron
QTY


Lot
N

Description
Red Chairs on Casters



N

Black Chairs on Casters

Serial#

Project



Asset Tag#

Asset ID

Condition
Poor
Poor

Certifications
Hazardous Materials Notice

Y

Certified By

TBYRON // : AM

Person/Department disposing of equipment that (i) may have been used to process hazardous materials, or (ii) may contain hazardous material which
cannot be removed, or (iii) which contains radioactive materials, must receive clearance as appropriate from the Environmental Health & Safety Dept, or
the Radiation Protection Office before this equipment may be surplused

Data Security Note

Y

Certified By

TBYRON // : AM

When including devices that may have internal storage (eg, copiers, printers, scanners, projectors, etc) on this form, please check with the
manufacturer for verification if storage exists If equipped with internal storage, it is the responsibility of the department to erase all data on the internal
storage or remove it before turning the device over to Surplus Devices with internal storage retain images made during the life of the equipment

Risk Management

Y

Certified By

TBYRON // : AM

Person/Department disposing of (i) tractors, mowers, skid steers or (ii) cars, trucks, vans and trailers, must provide signed copy of the surplus request

with signatures from your department and Surplus Property to remove the item (s) from Risk Management Insurance

Created By:

TBYRON

// : AM

Last Updated:

TBYRON

// : AM