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ARCHIVES AND RECORDS MANAGEMENT A DIVISION OF THE (Arizona State Library, Arhives and Public Records)

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ARCHIVES AND RECORDS MANAGEMENT
PART 1: REQUEST FOR APPROVAL
1.
2.
3.
4.
5.
6.
1.
2.
INSTRUCTIONS
Use this form ONLY for records that do not appear on an approved Retention Schedule.
In the top section enter the name of your Agency or Public Body, and include any subdivision breakdown
for division, department or unit.
Fill in the contact information for the requestor seeking approval.
List the record titles requested for disposition based on the terminology used in your office, and briefly
describe what the records are and their purpose.
Enter the earliest date of records you are requesting to be disposed under the Records Start Date column
and the latest date for the records to be disposed under the Records End Date column.
PRE-APPROVAL FOR UNSCHEDULED RECORDS DISPOSITION
WHEN RECORD SERIES ARE NOT ON AN APPROVED RETENTION SCHEDULE
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: 09/2019
An Equal Opportunity Employer
Enter the format of the records to be disposed under the Format: Paper, Digital, Microfilm column.
Enter the amount of records being disposed under the # of Files, Boxes, Reels; Electronic File Size
PART 2: CERTIFICATION
Do not complete Part 2 of the form until you have received signed authorization to do so and the
action authorized has been completed.
When the disposition action has occurred, complete the certificate section of the form and mail the
original to the Arizona State Library, Archives, and Public Records, Records Management Center.
Include the name, e-mail and phone number of the Records Officer for your agency or public body who
performed or arranged for the records disposition to occur (for transfering to Library, Archives and Public
Records, or with a contracted vendor for the destruction of the records). Your Records Officer must sign
the form.
ARIZONA STATE LIBRARY, ARCHIVES AND PUBLIC RECORDS
A DIVISION OF THE ARIZONA SECRETARY OF STATE
ARCHIVES AND RECORDS MANAGEMENT
PRE-APPROVAL FOR UNSCHEDULED RECORDS DISPOSITION
WHEN RECORD SERIES ARE NOT ON AN APPROVED RETENTION SCHEDULE
ARIZONA STATE LIBRARY, ARCHIVES AND PUBLIC RECORDS
A DIVISION OF THE ARIZONA SECRETARY OF STATE
PART 1: REQUEST FOR APPROVAL
REQUESTOR:
Pursuant to ARS §41-151.14 (4), the head of each state and local agency shall "Submit a list of public records
in the agency's custody that are not needed in the transaction of current business and that are not considered to
have sufficient administrative, legal or fiscal value to warrant their inclusion in established disposal
Public Body
Division
Department
Office/Unit
Records Officer Signature:
Name (type or print):
Phone:
Record Series Description
Records Start
Date
Records
End
Date
Format:
Paper,
Digital,
Microfilm
# of Files,
Boxes, Reels;
Electronic
File Size
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: 09/2019
An Equal Opportunity Employer
Polly Rosenbaum State Archives and History Building
ARCHIVES AND RECORDS MANAGEMENT
PRE-APPROVAL FOR UNSCHEDULED RECORDS DISPOSITION
WHEN RECORD SERIES ARE NOT ON AN APPROVED RETENTION SCHEDULE
ARIZONA STATE LIBRARY, ARCHIVES AND PUBLIC RECORDS
A DIVISION OF THE ARIZONA SECRETARY OF STATE
Transfer records to Arizona State Library, Archives and Public Records.
Destroy so as to render unusable.
AUTHORIZED BY:
Dr. Dennis Preisler, State Archivist
Date Approved
Records Analyst (or designee) Date Approved
Records Officer Signature Date
PART 2: CERTIFICATION
CERTIFICATE THAT RECORDS HAVE BEEN DISPOSED
As authorized under ARS §41-151.14 and ARS §41-151.19, I hereby certify that the records described in Part
1 (attached) have been disposed of according to the action authorized
THIS PORTION IS NOT TO BE FILLED OUT UNTIL AUTHORIZATION HAS BEEN SIGNED BY
ARIZONA STATE ARCHIVES AND RECORDS MANAGEMENT RECORDS BELOW
ACTION AUTHORIZED
Continue to hold until:
Transfer records to:
Phone: (602) 926-3815 • FAX: (602) 256-2838 • E-Mail: records@azlibrary.gov
Revised: 09/2019
An Equal Opportunity Employer
Phone:
Polly Rosenbaum State Archives and History Building
1901 W. Madison St. • Phoenix, Arizona 85009 • Home Page: http://www.azlibrary.gov/records
Name (type or print):
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Completed 20 July 2020

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