Company Name:

Contact Name:

Phone Number:

Email:

Zip Code or address of where media is located:

Estimate of when Equipment will be ready for destruction:

I require:

Attach an inventory to be destroyed:

Copy and paste inventory to be destroyed:

Amount of hard drives:

Amount of tapes (DLT, SDLT, LTO, etc.):

Any other descriptions, comments, or materials in need of destruction: