Fillable ARIZONA STATE LIBRARY, ARCHIVES AND PUBLIC RECORDS (Arizona State Library, Arhives and Public Records)

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ARIZONA STATE LIBRARY, ARCHIVES AND PUBLIC RECORDS (Arizona State Library, Arhives and Public Records)

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Vendor Contact Name (type or print):
Records Officer (type or print name):
Records Officer Signature:
Signature:
It is hereby certified that the above listed silver halide micrographics were processed in accordance
with the "Standards for Permanent Records" published by the Arizona State Library, Archives and
Public Records. It is further attested that the following equipment and procedures were used:
LIST OF SPECIFIC FILM ROLL NUMBERS or FICHE/JACKET IDENTIFICATION:
*PLEASE ATTACH ANY ADDITIONAL INFORMATION OR SCHEDULE ITEMS
RECORDS SERIES TITLE/ITEM # FROM RETENTION SCHEDULE & DATE RANGE:
Revised 12/2019
Government entity is responsible for the silver halide master film. If stored at vendor, vendor agrees to turn over
film to agency when contract ends, vendor is sold or goes out of business or at agency request.
Phone:
STORAGE LOCATION FOR OFFICIAL SILVER HALIDE MASTER FILM:
Phone:
ARIZONA STATE
LIBRARY, ARCHIVES AND PUBLIC RECORDS
A DIVISION OF THE ARIZONA DEPARTMENT OF STATE
Certificate of Compliance
with State Standards for Processing of Permanent Micrographics
METHELENE BLUE TEST FOR RESIDUAL THIOSULFATE PERFORMED:
PROCESSOR MAKE & MODEL:
Address:
MCN#:
Vendor Name (type or print):
Agency or Political Subdivision (type or print):
(authorized pursuant to ARS § 39-101)
Address:
FILM TYPE:
REDUCTION RATIO:
Email:
Date:
Date:
Phone: (602) 926-3815 • FAX: (602) 256-2838 • E-Mail: records@azlibrary.gov
Polly Rosenbaum State Archives and History Building
1901 W. Madison St. • Phoenix, Arizona 85009 • Home Page: http://www.azlibrary.gov/records
BI-WEEKLY DAILY WEEKLY OTHER
16mm Roll 35mm Roll Fiche Jacket
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ARIZONA STATE
LIBRARY, ARCHIVES AND PUBLIC RECORDS
A DIVISION OF THE ARIZONA DEPARTMENT OF STATE
1.
2.
3.
4.
5.
form.
INSTRUCTIONS
Revised 12/2019
Polly Rosenbaum State Archives and History Building
Agency will return the completed form to LAPR.
Important Note: Any forms that are incomplete will be returned to the agency.
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
In the top portion of this form, enter the vendor contact information and the agency or political subdivision contact
information and MCN# (provided on the approved Request for Microfilming of Public Records form).
If you do not know the MCN#, STOP. Please verify at this point that your agency has received permission from
the Library, Archives and Public Records to image documents and have an approved Request for Microfilming of
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Completed 20 July 2020

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