Voluntary Cognitive Relinquishment

DEPT OF COGNITIVE SANITATION // INTAKE FACILITY

Form CRI-7701 Rev. 3 (1986)

FOR OFFICIAL USE

Designation of Troublesome Recollection

Primary Clinical Diagnosis

CONDITION A - Inability to Forget (Standard)CONDITION B - Inability to Remember (Paradoxical)CONDITION C - Insufficient Brain FlaccidityCONDITION D - Future Memory DisturbanceCONDITION E - Non-Absurdist Memory Association Disorder

Estimated Temporal Origin

Emotional Resonance (1-10)

Justification for Erasure

Archival Disclosure Authorization

Optional // Form CRI-7701-D

I authorize the Institute to exhibit this recollection to the public, without attribution, in furtherance of the study of human memory.

NOTICE: Relinquished recollections are retained by the Institute for study. Absent this authorization, a recollection may be examined only by credentialed Institute personnel. No name is requested or recorded by this form. Exhibited recollections may be abridged or redacted at the discretion of the Archive.

I hereby certify that I am the sole owner of this memory. I understand that memory destruction is permanent, non-refundable, and may result in a sudden, lingering sense of loss or profound existential dread. I release the Cognitive Research Institute from all liability.