Form Ss Arc 941 - Role Designation Form

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ROLE DESIGNATION FORM
SS ARC 941 (R 6/13)
STATE OF LOUISIANA
SECRETARY OF STATE
TOM SCHEDLER
DIVISION OF ARCHIVES, RECORDS MANAGEMENT, AND HISTORY
BATON ROUGE, LOUISIANA
For Archives Use Only
Date Received: ________________
TO:
Records Management Section
Division of Archives Records Management and History
Updated: _____________________
P.O. Box 94125, Capitol Station
Baton Rouge, LA 70804-9125
Updated by: __________________
FAX (225) 922-1220
Instructions: This form is to be used to designate records coordinators (people who assist the agency records officer) and
records center coordinators with the State Archives Records Management Program. It can also be used to designate legal
and IT representatives for records management related topics. Unlike the Records Officer Designation Form, this form
does not need to be signed by the Chief Executive Officer. DO NOT USE this form to designate your agency’s Records
Officer (use form SS ARC 940 to do so). Please complete and return by fax or mail to the address or fax number
listed above.
PLEASE PRINT CLEARLY ALL INFORMATION REQUESTED BELOW.
1. Agency: _____________________________________________________________________________
2. Agency Mailing Address: _______________________________________________________________
3. Designee’s Role (Check all that apply):
[] Records Center Coordinator
[] Legal Contact
[] Records Coordinator
[] IT Contact
4. Designee Section/Office Representing:___________________________________________________
5. Designee Name: _____________________________________________________________________
6. Designee’s Title: _____________________________________________________________________
7. Designee’s E-mail Address: ___________________________@______________________________
8. Des Phone Number: (_____) _______- ________ 9. Des Fax Number: (_____) _______ - __________
The person listed above is appointed as the coordinator/contact for the section indicated until we notify your office or update the
information via renewal process through your office. In the event that our coordinator/contact changes, we will notify your office of
the change and our new designee within thirty days of any such change.
Submitter’s Signature:_________________________________________________________________
Submitters Title: ___________________________________Date: _____________________________

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