Form 14127 Microfilm Rental Order Form

OMB Control No: 3095-0059

Expiration date: 08/31/2007

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION (NARA)
MICROFILM RENTAL ORDER FORM
Privacy Act and Paperwork Reduction Act Public Burden statements are on the back of this page.
How The Microfilm Rental Program Works: General Information: The Microfilm Rental Program provides copies of selected National Archives Microfilm Publications for up to 30 days at a nominal fee per roll. The microfilm publications include all of the decennial population census records, 1790-1930, and related indexes, and other microfilm publications primarily of interest to family historians. You may use the film for a full 30 days, and then return it by mail to the address below. You may keep the film for an additional month only by remitting a check for $3.25 per roll. We must receive the check prior to the due date on the invoice before the extension can be granted. Users will be charged an additional $3.25 per roll for each week the film is overdue and an $18.00 replacement fee for each lost or damaged film. Any fees for overdue, damaged or lost film must be paid before we send additional film to a customer. Payment: By check or money order only, payable to National Archives Microfilm Rental Program. We do not accept payment by credit card. Cost: Rental fees and shipping rates are based on the following volume discounts:
	Rental Fee per roll		Shipping Fee per order
	1-4	$3.50	1-9 rolls	$6.00 (USPS)
	5-9	$3.00 (incl. 1-4)
	10-25	$2.50 (incl. 1-9)	10-25 rolls	$11.00 (UPS)
Start Up Kit: We also offer a Start Up Kit, consisting of all of the printed census catalogs, the Revolutionary War records catalog, and coupons for rental of your first two rolls, for $31.00. Purchase of the Start Up Kit is not required to rent microfilms. Information for Libraries: Libraries rent microfilm in the same way as individuals, except that they have two additional payment options not available to individuals. The options are (1) establishing a deposit account ($50 minimum to start) or (2) monthly billing based on usage. To set up a deposit account or monthly billing arrangement, contact our office at (301) 604-3699.

Please PRINT the following shipping information:

NAME
ADDRESS
CITY			STATE	ZIP
Daytime Telephone Number
Program Membership Number (if known):

Place your order by listing the publication (M or T plus number) and roll number below:

	Item	Publication #	Roll #		Item	Publication #	Roll #		Item	Publication #	Roll #
	1				10				19
	2				11				20
	3				12				21
	4				13				22
	5				14				23
	6				15				24
	7				16				25
	8				17
	9				18

Calculate your total payment:

Using the rental fee chart above, calculate the rental fee:	$____________
Subtract coupon savings, if applicable ($3.50 for 1, $7.00 for 2):	- $____________
Using the shipping fee chart above, add the shipping fee:	+ $____________
Add fee for Start Up Kit, if desired ($31.00):	+ $____________
Total:	$____________

MAIL THIS FORM AND YOUR CHECK OR MONEY ORDER TO:	National Archives Microfilm Rental Program P.O. Box 30
	Annapolis Junction, MD 20701-0030

Paperwork Reduction Act Privacy Burden 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 10 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, Maryland 20740. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. SEND COMPLETED FORMS TO THE ADDRESS INDICATED ON THE FRONT OF THIS 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 to process and track your microfilm rental request and to provide information to you. 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 from processing your microfilm rental request.

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION NA 14127 (06-07)