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Reproduce this form as needed. <br />forth Carolina Department of Cultural Resources <br />Division of ~Iisto~cal Resources <br />Government Records Branch <br />REQUEST FOR DISPOSAL OF ORIGINAL RECORDS DUPLICATED BY ELECTRO1vIC MEANS <br />TO Assistant Records Administrator <br />NwCr D1v~.,7~,on of A.~i~71.0~~a .Lt4+~~u~4e~ <br />Government Records Bunch <br />4GI5 Mail Service Center <br />Raleigh, NC 27G~~~4G15 <br />FROM Name <br />County <br />Agency or department <br />Phone number <br />Use this form tv request an amendment to your programs schedule from the Department of Cult~al Resources to dispose of paper <br />retards you have scanned, entered into databases, or otherwise duplicated through digital zmaging or other conversion to computer <br />ox digital envirvnmentsw This form. does not apply to records, which have been microfilmed or photocopied. Tn addition, this <br />form does not apply to records with a permanent retention or that are to be transferred to the State Archives Records with a <br />permanent retention or which will come to the State Archives must have a paper of microfilm copy. <br />A completed copy of the "Electronic Records Production Control Self=Warran " foam. must be attached. t can be found ~n the North <br />Carolina Guidelines for Mara ' Public Records Produced b Information Technolo S stems. <br />RECORDS T~r~ :. '` ~ DESC~IOrr ~ - wcLUS~ Qr~,~Ix~ ~~ M~cRo~~n~ RETENTION' <br />DATES (YES DR Nod ' ;' 'PERIOD <br />Requested by: ~ 7 <br />Signature Title Date <br />Approved by: ~ 7 <br />Signature Bead of Governing Board Date <br />Concurred by: <br />~as indicated) Signature Assistant Records Administrator Date <br />NC Division of Historical Resources <br />94 <br />