University of Pennsylvania Records Center
Mezzanine, 4015 Walnut St. Philadelphia, PA  19104-6198
(215) 898-9432    urc@upenn.edu

RECORDS DESTRUCTION REQUEST

PERSON MAKING REQUEST  
Date:
Date	

Name of Individual Making Request:
Name	

Customer Number:
No.	

Phone Number:
No.	

Hospital/Office/School:
Center	

Department/Division:
Dept.	

	
DESTRUCTION AUTHORIZATION:
My signature authorizes the destruction of the records listed.
____________________________	
__Title_________________________	
_______________________	
_______________	

Signature	
Title	
Date	
Time	

Box Number	
Description of Contents	

No.	
Description	

No.	
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Description	

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No.	
Description