Kingdom of Saudi Arabia ‫ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ‬

Ministry of National Guard - Health Affairs ‫ ﺍﻟﺸﺆﻭﻥ ﺍﻟﺼﺤﻴﺔ‬- ‫ﻭﺯﺍﺭﺓ ﺍﻟﺤﺮﺱ ﺍﻟﻮﻃﻨﻲ‬

Scrap Disposal Authorization Form - Assets

Part I - To be completed by the Requesting Department

Requester Name : Badge No. :

Position : Ext. No. :

Department : Fax No. :

I request to dispose the following item: Equipment Furniture Other

GP/KN Number : Serial # : Model # :

Manufacturer : Quantity :

Description : PO # :

Reason For Disposal : Obsolete Damaged In Excess Worn-out Contaminated

Expired Unusable Other

Acquisition Date :

Comments/Remarks :

Approved By:

Requester Signature Date Department Head/Chairman Date

(Name & Signature)
Part II - To be completed by the Technical Department

Evaluated by : Technical Report Attached

Recommendation : Obsolete Damaged Excess Worn-out Comtaminated

Comments :

Technician Badge No. Date Department Head/Chairman Date

(Name & Signature) (Name & Signature)
Part III - To be completed by Property Management

Data Verification By:

IR No. : Acquisition No. :

Department Head Date

(Name & Signature)
Part IV- To be completed by the Disposal Committee

Approved By: Approved Disapproved

Comments :
Disposal Committee Stamp

Non-Clinical Form Rev. 01/2014 Ref# APP 1429-31 Page 1 of 1 Appendix A O&M# 0401-0229
Distribution: Original - Disposal Committee cc: Custodian Scrap & Salvage Yard Requesting Department Property Management