14110 Item Approval Request List

Special Media Archives Services Division (NWCS) Item Approval Request List OMB No.: 3095-0025

National Archives and Records Administration Expires: 08/31/2007

Room 3360 Telephone: 301-837-3520

8601 Adelphi Road Facsimile: 301-837-3620

College Park, MD 20740-6001 E-Mail: [email protected]

A. Customer/Researcher Information
Customer Name/Preferred Contact					Date Submitted
Company Name
Street Address
City		State	Zip /Mailing Code			Country
Telephone	Facsimile (FAX)			E-Mail

NWCS Use Only
Order Number	Assignee/Date

B. INSTRUCTIONS: Complete boxes B1, B2, and B3. We cannot “approve” incomplete listings. NOTE: “Pending” codes: “I”=Intermediate exists; “P”= no intermediate; “2” = requires written permission from donor, donor’s representative, or copyright, or copyright holder’s representative to reproduce.
1. Control and reel number (Each reel must be on a separate line)	2. Title/Subject	16 mm	35 mm	VT	Archival Format	Running Time	3. Order Copy Format	Approval And Pending Codes

NA FORM 14110 (5-04)

PAPERWORK REDUCTION ACT PUBLIC BURDER STATEMENT

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Public burden reporting for this collection of information is estimated to be 15 minutes per response. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to National Archives and Records Administration (NHP), 8601 Adelphi Road, College Park, MD 20741-6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. SEND COMPLETED CORM TO THE ADDRESS AT THE TOP OF THE FORM.

PRIVACY ACT STATEMENT

Sections 2104(a) and 2108 of Title 44 of the U.S. Code authorize the collection of this information. The primary use of this information is by NARA staff to process and track your reproduction request and to provide information to you and the vendor you select to make your reproduction. The information may also be used to facilitate preparation of statistical and other reports. Furnishing the information requested on this form is voluntary, but failure to do so will prevent NARA processing your reproduction request.

NA FORM 14110 (5-04)

CONTINUATION SHEET

ITEM APPROVAL REQUEST LIST

Name/Company Name

Order Number

Page _______of_______

B. INSTRUCTIONS: Complete boxes B1, B2, and B3. We cannot “approve” incomplete listings. NOTE: “Pending” codes: “I”=Intermediate exists; “P”= no intermediate; “2” = requires written permission from donor, donor’s representative, or copyright, or copyright holder’s representative to reproduce.
1. Control and reel number	2. Title/Subject	16 mm	35 mm	VT	Archival Format	Running Time	3. Order Copy Format	Approval and Pending Codes

NA FORM 14110 (5-04)