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ee a a a nS ee Oe A OR Ce eel Serial Removal Charge Out rm . 4e21 (Rev, 2-14-05) . —_ INSTRUCTIONS: This form is to be removed from file by a Filing Unit eaptoyee only upon the return of the item. Type of Mail 5 ; Date of Mail £_} Report (—j Incoming Jetter {-] Oulgoing letter (_) Memorandum . © Airtel (_) Teletype (~) Enclosure (describe} K otek (ey Laboratory Work Sheet ([] Personne] Security Questionnaire (PSQI ([) Loyalty Form (C] Other (describe) Removed for Removed by Date of Removal yr. Mrs. Bis SYS /-G-7¢ Reason for Removal (7} For copying (if for another agency, list agency and dale of request.) CC) To send to (_] Te ailnch to (7) For office use (For change to another file C7 Olher (Specify) 4A 2 —— . maa Complete File and Serial Number = | 2) 2 Ooo ~ re) } © Ss