This is to certify that I have turned in all records and equipment and have cleared all parking tickets as indicated below:




    Yes No  A printout of final grades that have been entered into the system via the Internet. Please print your name on the top of each class roll.

    Yes No     Original Class Record book (Grade book) has been turned  in to the Academic Division or Evening Division.

    Yes No    All Library Books have been returned to the Library.

    Yes No    All Audio-Visual Equipment has been returned to Media Services.
    Yes No  Delgado Parking Tickets have been paid or cleared through Campus Police.

    Yes No  Quarterly Safety Training has been reviewed and acknowledgement receipt has been electronically submitted.

    If necessary to use library books or audio-visual equipment during the semester break, indicate what books and/or audio-visual equipment you will be using.

    ________________________________________ _________________
    Signature of Faculty Member Date


    Form 2122/002 (4/12)

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