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Reproduce this.form as needed. <br /> North Carolina Department of Cultural Resources <br /> Division of Archives and Records <br /> Government Records Section <br /> REQUEST FOR DISPOSAL OF UNSCHEDULED RECORDS <br /> TO Assistant Records Administrator <br /> N.C. Division of Archives and Records <br /> Government Records Section <br /> 4615 Mail Service Center <br /> Raleigh, NC 27699-4615 <br /> FROM Name <br /> County <br /> Agency or department <br /> Phone number <br /> In accordance with the provisions of G.S. 121 and 132,approval is requested for the destruction of records listed below. These <br /> records have no further use or value for official or administrative purposes. <br /> RECORDS TITLE DESCRIPTION INCLUSIVE DATES QUANTITY MICROFILMED? RETENTION <br /> (YES OR No) PERIOD <br /> Requested by: <br /> Signature Title Date <br /> Approved by: <br /> Signature Head of Governing Board Date <br /> Concurred by: <br /> (as indicated) Signature Assistant Records Administrator Date <br /> NC Division of Archives and Records <br /> 117 <br />