Date:

Transferring Office:

Contact person:

(please do not allow students to sign the form or act as a contact person for the transmittal process):

Phone number and email address of contact person:

Description of documents to be transferred

Title of records:

Date Span:

Description of records:

.

Are documents confidential or use-restricted in any way?

If yes, please describe the nature of and type of confidentiality or other restriction.

.

Release of Records

I hereby transfer the custody of the described records to the College Archives. I understand that this transfer constitutes a permanent transfer to the College Archives and that, unless the confidential nature of the records is indicated above, the records can be examined without restriction. I affirm that I am authorized by my Department to make this transfer of records, artifacts and other documents to the College Archives. I understand that transferred materials which are out of scope or which duplicate documents in the College Archives may be sold or otherwise disposed of by the College Archives.

______________________________________________________         _________

Signature of authorized Departmental representative              Date

Please sign the form and include with the shipment.