Legal Disposal Destruction Certification Form
Certify the lawful disposal and destruction of materials or records using this form.
Full Name of Certifier
*
First Name
Last Name
Organization Name
*
Email Address
*
example@example.com
Date of Disposal/Destruction
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Description of Materials or Records Disposed
*
Method of Destruction
*
Please Select
Shredding
Incineration
Pulverization
Chemical Treatment
Other
Location of Disposal/Destruction
*
Was a witness present?
*
Yes
No
If yes, provide witness name
I certify that the above information is accurate and that the disposal/destruction was conducted in accordance with applicable laws and organizational policies.
Submit Certification
Should be Empty: