Free 49433.PDF - Indiana

STATE MICROGRAPHICS RECORD TRANSMITTAL AND RECEIPT
State Form 49433 (7-99)

Indiana Commission on Public Records 402 W. Washington St., Rm. W472 Indianapolis, Indiana 46204 Telephone: (317) 232-3373 Fax: (317) 233-1713

INSTRUCTIONS:

1. 2. 3. 4.

Complete and send entire form to State Micrographics prior to microfilming. Use one transmittal for each record series number. A receipt will be given at the time the records are transferred. Transmittal must be typed or printed in order to ensure accuracy and legibility. TO: FROM:
Contact person / Complete name/division and address of origin

STATE MICROGRAPHICS INDIANA COMMISSION ON PUBLIC RECORDS 100 North Senate Avenue, N055 Indianapolis, Indiana 46204 Telephone (317) 232-3381 Fax (317) 233-0412

Fund / Object / Center

AUTHORIZATION TO MICROFILM / PER RETENTION SCHEDULE
Signature of records / information coordinator Telephone number Date signed FAX

RECEIPT OF RECORDS
Signature of Micrographics employee receiving records Printed name of Micrographics employee receiving records

Record series number

Number of boxes

Name of delivery person

Date / time

VERIFICATION
Agency Signature of undersigned agrees to verify microfilm upon receipt.

Distribution: White - Agency; Canary - Micrographics

STATE MICROGRAPHICS RECORD TRANSMITTAL AND RECEIPT
State Form 49433 (7-99)

Indiana Commission on Public Records 402 W. Washington St., Rm. W472 Indianapolis, Indiana 46204 Telephone: (317) 232-3373 Fax: (317) 233-1713

INSTRUCTIONS:

1. 2. 3. 4.

Complete and send entire form to State Micrographics prior to microfilming. Use one transmittal for each record series number. A receipt will be given at the time the records are transferred. Transmittal must be typed or printed in order to ensure accuracy and legibility. TO: FROM:
Contact person / Complete name/division and address of origin

STATE MICROGRAPHICS INDIANA COMMISSION ON PUBLIC RECORDS 100 North Senate Avenue, N055 Indianapolis, Indiana 46204 Telephone (317) 232-3381 Fax (317) 233-0412

Fund / Object / Center

AUTHORIZATION TO MICROFILM / PER RETENTION SCHEDULE
Signature of records / information coordinator Telephone number Date signed FAX

RECEIPT OF RECORDS
Signature of Micrographics employee receiving records Printed name of Micrographics employee receiving records

Record series number

Number of boxes

Name of delivery person

Date / time

VERIFICATION
Agency Signature of undersigned agrees to verify microfilm upon receipt.

Distribution: White - Agency; Canary - Micrographics