Broadcast Media Destruction Certification Form
Please complete all fields below to certify the destruction of broadcast media according to your organization's procedures.
Organization Name
*
Contact Person Full Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Media Type
*
Please Select
Tape
Disk
Optical Media
Hard Drive
Server
Other
Media Identifier or Reference Number
*
Destruction Method
*
Please Select
Degaussing
Physical Shredding
Incineration
Overwriting
Other
Date of Destruction
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Destruction Location
*
Witness Full Name
*
First Name
Last Name
Certification: I hereby certify that the above broadcast media has been destroyed as described and in accordance with all applicable procedures.
*
Submit Certification
Submit Certification
Should be Empty: