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Reproduce this form as needed. <br />North Carolina Department of Cultural Resources <br />Division of I3istorical Resources <br />Government Records Branch <br />REQUEST FOR DISPOSAL OF ORIGINAL RECORDS DUPLICATED BY ELECTRONIC MEANS <br />TO <br />FROM <br />Assistant Records Administrator <br />N.C. Division of Historical Resources <br />Government Records Branch <br />4615 Mail Service Center <br />Raleigh, NC 27699-4615 <br />t~T~ <br />r`~ n+~, <br />Agency or department <br />Phone number <br />Use this form. to request an amendment to your programs schedule from the Department of Cultural Resources to dispose of paper <br />records you have scanned, entered into databases, or otherwise duplicated through digital imaging or other conversion to computer <br />or digital environments. This form does not apply to records, which have been microfilmed or photocopied. In addition, this <br />form does not apply to records with a permanent retention ox 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-Warranty" form must be attached. It can be found in the North <br />Carolina Guide lines for Mana ~ Publtc Kecords Produced b lntormatton lectlr1010 J stems. <br />RECORDS TITLE DESCRIPTION INCLUSIVE <br />DATES QUANTITY MICROFILMED? <br />(YES OR NO) RETENTION <br />PERIOD <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Requested by: <br />Signature <br />Approved by: <br />Signature <br />Concurred by: <br />(as indicated) Signature <br />Title Date <br />Head of Governing Board Date <br />Assistant Records Administrator Date <br />NC Division of Historical Resources <br />94 <br />