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A DIVISION OF THE ARIZONA DEPARTMENT OF STATE (Arizona State Library, Arhives and Public Records)

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Page 1 of 5
ARCHIVES AND RECORDS MANAGEMENT Submission date:
Approval date: Expiration date: Microfilm Control #:
A.
B.
Revised 10/2019
ARIZONA STATE
NON-PERMANENT RETENTION
The applicant agrees that the microfilm copy meets or exceeds state standards per ARS §39.101.
The applicant will institute a quality control process that includes inspecting at least 20% of all records to
ensure that all information on the microfilmed versions are legible.
REFER TO THE APPLICABLE LAPR
STANDARDS
BEFORE COMPLETING THIS FORM. CHECK ALL
OF THE CATEGORIES THAT APPLY IN PART 1 AND INITIAL ALL BOXES IN PART 2 OF THIS FORM.
PART 1: APPROVAL
PERMANENT RETENTION
The applicant recognizes that archival (permanent) records covered by this request are to be retained permanently,
and that the microfilm copy meets or exceeds the state standards per ARS §39.101.
The applicant recognizes that the microfilmed copy may become the official copy, and if the source records are to
be destroyed, 100% of the records will be verified to ensure that all the information on the microfilmed versions
is legible.
LIBRARY, ARCHIVES AND PUBLIC RECORDS
A DIVISION OF THE ARIZONA DEPARTMENT OF STATE
MCN
REQUEST FOR MICROFILMING OF PUBLIC RECORDS
ARS §41-151.16 A. Each agency of this state or any of its political subdivisions may implement a program for the
production or reproduction by photography or other method of reproduction on film, microfiche, digital imaging or
other electronic media of records in its custody, whether obsolete or current, and classify, catalogue and index such
records for convenient reference. The agency, before the institution of any such program of production or
reproduction, shall obtain approval from the director of the types of records to be produced or reproduced and of the
methods of production, reproduction and storage and the equipment which the agency proposes to use in connection
with the production, reproduction and storage. Approval pursuant to this subsection is necessary for digitizing
programs but not for individual instances of digitization. On approval from the director, the source documents may be
destroyed, but only after an administrative audit and after safeguards are in place to protect the public records
pursuant to section 41-151.15, subsection A.
Agency or Political Subdivision Title:
(here after referred to as "Applicant")
The Applicant requests authorization from the Arizona State Library, Archives and Public Records [here after referred to as LAPR], in
accordance with ARS §41-151.16, to microfilm records described below and agrees to comply with the conditions and standards in
Parts 1 and 2:
Record Series Title as Stated on Approved Schedule
Schedule Number or Date
Item #
Page 2 of 5
ARCHIVES AND RECORDS MANAGEMENT Submission date:
Approval date: Expiration date: Microfilm Control #:
ARIZONA STATE
LIBRARY, ARCHIVES AND PUBLIC RECORDS
A DIVISION OF THE ARIZONA DEPARTMENT OF STATE
MCN
REQUEST FOR MICROFILMING OF PUBLIC RECORDS
C. MICROFILM INFORMATION
i.
State Records Management Center
ii.
Processing performed by:
State Records Management Center
iii. Microfilm created using the following camera types:
Planetary Rotary Digital
iv. Film Format:
35mm 16mm (only permitted for letter/legal size source documents)
v. Copy for Office Use:
Microfilm Diazo Digital image
DIGITAL USE COPY
a.
b.
D.
Record Disaster recovery Reference use
E.
i.
SILVER MASTER, 1ST GENERATION RECORD
State Archives
PHYSICAL LOCATION OF MICROFILM
The Applicant ensures that the microfilmed copies of the records are kept as specified on a records retention
schedule approved by the Arizona State Library, Archives and Public Records. The microfilm will be retained as
follows:
Submitting Agency
State Records Management Center
Vendor
Revised 10/2019
Vendor name
A digital use copy will be created and will be retained for the period specified on a records schedule
approved by LAPR.
The digital copy meets or exceeds the Minimum Standards for Digital Imaging or Scanning Textual
Documents standard.
MICROFILM WILL BE USED FOR:
Submitting Agency
Vendor
Vendor name
Submitting Agency
Vendor
Filming performed by:
Page 3 of 5
ARCHIVES AND RECORDS MANAGEMENT Submission date:
Approval date: Expiration date: Microfilm Control #:
ARIZONA STATE
LIBRARY, ARCHIVES AND PUBLIC RECORDS
A DIVISION OF THE ARIZONA DEPARTMENT OF STATE
M
CN
REQUEST FOR MICROFILMING OF PUBLIC RECORDS
ii.
SILVER DUPLICATE, 2ND GENERATION COPY
State Archives
iii.
DIAZO DUPLICATES, 3RD GENERATION COPIES
State Archives
F. SOURCE DOCUMENTS WILL BE:
Retained Destroyed Transferred to State Archives
BY WHOM:
State Archives
PART 2: CERTIFICATION
For 35mm film, the applicant certifies that records filmed may be larger than 11' x 14" and do
not exceed 1:24 reduction. (Standards for Permanent Records )
Applicant initials
For 35mm film of architectural, engineering and topographical drawings not exceeding 36" x
48.6", the applicant certifies that records filmed do not exceed 1:30 reduction. (Standards for
Permanent Records)
Applicant initials
Applicant initials all below
The Applicant certifies that the microfilmed copies meet or exceed current state standards.
Applicant initials
The Applicant certifies that a Certificate of Compliance form is used to certify that the microfilm
was processed in accordance with standards published by LAPR. The certificate will be filed
annually if the filming is not performed by LAPR, Records Management Center.
Applicant initials
For 16mm film, the applicant certifies that records filmed do not exceed 11" x 14" with a 1:32
reduction. (Standards for Permanent Records )
Applicant initials
Revised 10/2019
Submitting Agency
State Records Management Center
Vendor
GENERAL REQUIREMENTS FOR ALL OPTIONS LISTED ABOVE
Submitting Agency
State Records Management Center
Vendor
Submitting Agency
State Records Management Center
Vendor
Page 4 of 5
ARCHIVES AND RECORDS MANAGEMENT Submission date:
Approval date: Expiration date: Microfilm Control #:
ARIZONA STATE
LIBRARY, ARCHIVES AND PUBLIC RECORDS
A DIVISION OF THE ARIZONA DEPARTMENT OF STATE
MCN
REQUEST FOR MICROFILMING OF PUBLIC RECORDS
REQUESTOR:
AUTHORIZED BY:
Dr. Dennis Preisler, State Archivist Date A
pproved
Records Analyst (or designee) Date Approved
ACTION AUTHORIZED
As authorized under ARS §41-151.16, the Arizona State Library, Archives and Public Records authorizes the Applicant
to reproduce these records using the methods of production, reproduction and storage and the equipment which the
agency proposes following these procedures for a period of five years. Failure to comply with these procedures is a
violation of ARS §41-151.16.
Polly Rosenbaum State Archives and History Building
1901 W. Madison St. • Phoenix, Arizona 85009 • Home Page: http://www.azlibrary.gov/records
Phone: (602) 926-3815 • FAX: (602) 256-2838 • E-Mail: records@azlibrary.gov
Revised 10/2019 An Equal Opportunity Employer
Records Officer Signature:
Date:
Name (type or print):
Records Officer (type or print name):
Signature:
E-Mail:
Agency or Political
Subdivision Title:
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Page 5 of 5
ARCHIVES AND RECORDS MANAGEMENT Submission date:
Approval date: Expiration date: Microfilm Control #:
ARIZONA STATE
LIBRARY, ARCHIVES AND PUBLIC RECORDS
A DIVISION OF THE ARIZONA DEPARTMENT OF STATE
MCN
REQUEST FOR MICROFILMING OF PUBLIC RECORDS
PART 1: REQUEST FOR APPROVAL
1.
2.
1.
2.
Revised 10/2019 An Equal Opportunity Employer
Once approval has been granted a copy of the request will be forwarded to the agency. Please note the
Microfilm Control # (MCN#) provided by LAPR at the top of the form. This number will be used in conjunction
with the Certificate of Compliance , to be used by the agency and their vendor and returned to LAPR.
Polly Rosenbaum State Archives and History Building
1901 W. Madison St. • Phoenix, Arizona 85009 • Home Page: http://www.azlibrary.gov/records
Phone: (602) 926-3815 • FAX: (602) 256-2838 • E-Mail: records@azlibrary.gov
Check all items that apply for sections A through F of the approval portion of this form.
PART 2: CERTIFICATION
Read and initial all boxes in the certification portion of this form.
Enter Requestor name, Records Officer name, phone number and email; then the Records Officer must
sign and date the form.
describe what the records are and their purpose.
Refer to the applicable LAPR Standards before completing this form.
INSTRUCTIONS
In the top section enter the name of your Agency or Public Body, and include any subdivision breakdown for division,
department or unit.
In the table provided, fill in the Record Series Title(s) for which the requestor is seeking approval. Include the
schedule number or date and the item numbers as they appear on the approved retention schedule.
If items are not currently listed on an approved schedule, list them following the terminology used in office and briefly
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A DIVISION OF THE ARIZONA DEPARTMENT OF STATE (Arizona State Library, Arhives and Public Records)

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Completed 27 January 2021

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