State Form 49433 - State Mecrographics Record Transmittal And Receipt
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1STATE MICROGRAPHICS RECORD TRANSMITTAL AND RECEIPT
Indiana Commission on Public Records
402 W. Washington St., Rm. W472
State Form 49433 (7-99)
Indianapolis, Indiana 46204
Telephone: (317) 232-3373
Fax:
(317) 233-1713
INSTRUCTIONS:
1. Complete and send entire form to State Micrographics prior to microfilming.
2. Use one transmittal for each record series number.
3. A receipt will be given at the time the records are transferred.
4. 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
Fund / Object / Center
Fax
(317) 233-0412
RECEIPT OF RECORDS
AUTHORIZATION TO MICROFILM / PER RETENTION SCHEDULE
Signature of records / information coordinator
Signature of Micrographics employee receiving records
Date signed
Telephone number
FAX
Printed name of Micrographics employee receiving records
Record series number
Number of boxes
Name of delivery person
Date / time
VERIFICATION
Signature of undersigned agrees to verify microfilm upon receipt.
Agency
Distribution: White - Agency; Canary - Micrographics
STATE MICROGRAPHICS RECORD TRANSMITTAL AND RECEIPT
Indiana Commission on Public Records
402 W. Washington St., Rm. W472
State Form 49433 (7-99)
Indianapolis, Indiana 46204
Telephone: (317) 232-3373
Fax:
(317) 233-1713
INSTRUCTIONS:
1. Complete and send entire form to State Micrographics prior to microfilming.
2. Use one transmittal for each record series number.
3. A receipt will be given at the time the records are transferred.
4. 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
Fund / Object / Center
Fax
(317) 233-0412
RECEIPT OF RECORDS
AUTHORIZATION TO MICROFILM / PER RETENTION SCHEDULE
Signature of records / information coordinator
Date signed
Signature of Micrographics employee receiving records
Telephone number
FAX
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
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