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COPIERS Customer Owned E uii ment Removal Form <br />NORTHWEST Customer: Kittitas county Commissioner's Office <br />lVnw 7tluad. Now $o7uffon8. <br />601 Dexter Ave N Seattle, WA 98109 Address: 205 West 5th Ave, Suite 108 <br />City, State, Zip: Ellensburg, WA 98926 <br />P: (206) 282-1200 F: (206) 282-2010 Phone: (509} 962-7508 <br />www.copiersnw.com <br />Account Rep: Curtis Bell <br />This document must be completed prior to authorizing and scheduling any CUSTOMER OWNED "Trade -Ins" which includes any equipment customee <br />puf-Chased from CNW or another Vendor. Leased Equipment originating from Copiers Northwest (CNW) does not require any forms. <br />ACCEPTED BY COPIERS NORTHWEST <br />Authorized Signature Required / Date <br />ACCEPTED BY CUSTOMER <br />Authorized Signature Required / Date <br />Printed Name / Title Revision 19.05 Printed Name / Title <br />page 3 <br />NON-CNW LEASED EQUIPMENT - do not use this form; customer owned equipment {CNW or other) only. <br />Please use the "NON-CNW Leased Equipment Removal Form" to authorize removal of NON-CNW leases. <br />Line <br />Status ID # Make Model Serial <br />1 <br />Customer Owned Canon C7260 <br />2 <br />Customer Owned <br />3 <br />Customer Owned <br />4 <br />Customer Owned <br />5 <br />Customer Owned <br />6 <br />Customer Owned <br />7 <br />Customer Owned <br />8 <br />Customer Owned <br />9 <br />Customer Owned <br />10 <br />Customer Owned <br />11 <br />Customer Owned <br />12 <br />Customer Owned <br />13 <br />Customer Owned <br />14 <br />Customer Owned <br />15 <br />Customer Owned <br />16 <br />Customer Owned <br />17 <br />Customer Owned <br />18 <br />Customer Owned <br />19 <br />Customer Owned <br />20 <br />Customer Owned <br />21 <br />Customer Owned <br />22 <br />Customer Owned <br />23 <br />Customer Owned <br />24 <br />Customer Owned <br />25 <br />Customer Owned <br />26 <br />Customer Owned <br />27 <br />Customer Owned <br />28 <br />Customer Owned <br />29 <br />Customer Owned <br />30 <br />Customer Owned <br />31 <br />Customer Owned <br />32 <br />Customer Owned <br />33 <br />Customer Owned <br />34 <br />Customer Owned <br />Please use a similar format to list additional CUSTOMER OWNED EQUIPMENT on supplementary pages. <br />THIS SECTION FOR CUSTOMER OWNED EQUIPMENT ONLY: <br />I the undersigned agree that all equipment marked and/or referred to as "Customer Owned" 'Trade In" or "Disposal" is free and clear of any liens or <br />encumbrances. The title and ownership of this equipment is transferred to Copiers NW, Inc. Copiers NW is under no circumstance responsible for any data, <br />documents, images, or other information stored on or in the device, the device hard drive(s), or any memory module(s). <br />ACCEPTED BY COPIERS NORTHWEST <br />Authorized Signature Required / Date <br />ACCEPTED BY CUSTOMER <br />Authorized Signature Required / Date <br />Printed Name / Title Revision 19.05 Printed Name / Title <br />page 3 <br />