EQUIPMENT CHANGE REQUEST/NOTIFICATION
Rensselaer Polytechnic Institute
Office of Property Administration - Modular 01 Bldg.

 Requestor Name  Date
 Department  Telephone No.

List the requested ACTION(S) in Section I using the codes listed below; Sign in Section II, as applicable.
T1
 TRANSFER - to another department
T2
 TRANSFER - to temporary storage (Chasen Building/Stone Warehouse)
L2
 LOCATION CHANGE - to another on-site location
L3
 LOCATION CHANGE - to an off-site location (at home)
D1
 TRADE IN - toward purchase of new equipment
D2
 OBSOLETE equipment; will be discarded or cannibalized for parts.
D3
 NON-REPAIRABLE equipment; discard or cannibalize for parts
D4
 LOST or STOLEN equipment; will will not be replaced (Attach copy of Public Safety Report to this form)
D5
 Other (explain)

SECTION I: EQUIPMENT INFORMATION
Action
Code
RPI Tag No.
Description
New Dept / Location
(List Bldg, Room No. Address, as appropriate)
       
       
       
       
       
       

SECTION II: APPROVAL SIGNATURES
I (WE) CERTIFY THAT THE LOCATION CHANGE AND/OR DISPOSITION CONSTITUTES INSTITUTE BUSINESS AND WILL ASSUME RESPONSIBILITY FOR THE EQUIPMENT LISTED.
Approved by:
Typed/Printed Name
Signature and Date
 Originating Dept. Chair/Director    
 Receiving Dept. Chair/Director    
 Contracts and Grants    
 Office of Property Administration    

For Office of Property Administration Use Only
 Record changed by:  Date:
 File Reference/Notes: