The Request For Deletion (RFD) form comprises a single sheet of paper, two sides.
                       REQUEST FOR DELETION

In the interest of employee safety, our employees are required to wear
uniforms equipped with protective media to discourage others from
exposing them to dangerous situations or environments (e.g.
establishments where fire exits are chained shut illegally or the
like), or to falsely accuse our employees of crimes (such as
shoplifting and the like).

Our employee uniforms capture images, photometric measurements, and or
other measurement information and the like, which may have been and
may continue to be transmitted and recorded at remote locations.
Furthermore, our employees are required to document, via more
traditional photographic means, any incident in which there is a
perceived or suspected safety hazard, or any incident in which there
might be potential for a crime to be committed in the future (such as
when an employee presents a company credit card, when an employee
makes a purchase but is not given a receipt that provides proof of the
purchase such that a false shoplifting accusation could be
forthcoming, or when cash is being handled by one of our employees).
For YOUR protection, our employees are also required to photograph
each person they interact with, as well as maintain a recording of the
conversation, in order to pre-empt any disputes regarding return of

If you feel that one of our employees has documented something within
your establishment that you do not wish to have remaining on file in our
image archives, or if you feel that your likeness should not remain on file
in our archives you may submit a REQUEST FOR DELETION (RFD) to our
employee who will forward it to our Company Headquarters.

Your RFD, if properly completed in full, will be presented to a
committee, and a decision will be made as to whether to expunge said
image(s) or to flag said images as noteworthy (e.g. by submitting an
RFD, you should be aware that it may in fact cause your likeness to be
flagged as suspicious or of special interest to the permanent

Part I:   Declaration of reason for RFD (please circle only one):

A  National security:
   You must be a government establishment or have government affiliation
   (such as government funding) to select this option.

B  Company confidential:
   B1: A trade secret has been inadvertently documented by our employee.
   B2: Strategic marketing plans have been inadvertently documented by
       our employee.
   B3: Other company confidential ____________________________________
   (please describe, use additional page if necessary)

C other _______________ (please describe, use additional page if necessary)

Part II:  Declaration of abstinence from willful destruction of evidence
          of a criminal act.

In recognition of the fact that measurement (photometric, radar, or
otherwise) data captured by our employee may comprise evidence, in the
context of a possible future criminal investigation against me or my
establishment, I, the undersigned, declare that my REQUEST FOR
DELETION is not for purposes of concealing criminal activity of myself
or of others in my establishment.

I assert that my RFD is not intended to hide criminal activity of any
kind occurring within my establishment, including, but not limited to
fire exits chained or otherwise fastened shut illegally, or criminal
activity of myself.  I further assert that my RFD is not for purposes
of concealing or destroying evidence of harassment of a
representative of Personal Safety Devices (PSD), or to conceal
discrimination against a PSD employee.

Name: ______________________________

Social Security Number: _____________________________

Signature: ___________________________

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(PSD employee to assist in centering thumb print in box)


You should understand that public safety (including that of our
employees) is for YOUR benefit.  For example, by eliminating credit
card fraud, the credit card companies are able to continue to charge
lower profit margins, which increases your store profits.  As you are
well aware, your use of surveillance cameras has reduced costs and
benefits the customer (e.g. you often use the words "for YOUR
protection you are being videotaped").  We appreciate your concern for
your customers (us), and wish to return the gift of public safety to
your establishment, in a manner in which we can all benefit, through
the creation of a utopian world order of zero crime.

-----------------------------for PSD use only---------------------------
Image index and type (e.g. v000100.jpg to v000199.jpg, or v123.pic),
to be completed by PSD employee prior to submission to Company Headquarters

__________.jpg  to  __________.jpg    ______.pic   ______.mpg   ______.dat

__________.jpg  to  __________.jpg    ______.pic   ______.mpg   ______.dat

__________.jpg  to  __________.jpg    ______.pic   ______.mpg   ______.dat
(use additional page if necessary)