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Name:

Phone:

Email:

Department:

Index:

Fund:

Organization:

Account:

Program:

Have items been picked up? * This field is required.*

Yes

No

Do you need FAMA assistance? * This field is required.*

Yes

No

Serial Number (equipment only)

Property Information

Tag Number:

Description:

Quantity:

Condition Please Select Excellent Good Fair Poor

Serial Number (equipment only):

Location:

Property Information

Tag Number:

Description:

Quantity:

Condition: Please Select Excellent Good Fair Poor

Serial Number (equipment only):

Location:

Property Information

Tag Number:

Description:

Quantity:

Condition: Please Select Excellent Good Fair Poor

Serial Number (equipment only):

Location:

Property Information

Tag Number:

Description:

Quantity:

Condition: Please Select Excellent Good Fair Poor

Serial Number (equipment only)

Location:

Property Information

Tag Number:

Description

Quantity:

Condition: Please Select Excellent Good Fair Poor

Location:

Submitting this form indicates you and your department’s willingness to use department funds to pay for removal of these items. The Physical Plant will charge the account(s) you listed.

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