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DCR- DHR- ARS- GRB -RC10 (rev.5 /02) Reproduce this form as needed. <br />North Carolina Department of Cultural Resources <br />Division of Historical Resources <br />Government Records Branch <br />REQUEST FOR DISPOSAL OF ORIGINAL RECORDS DUPLICATED BY ELECTRONIC MEANS <br />TO 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 />FROM Name <br />Countv <br />Agency or department <br />Phone number <br />Use this form to request approval from the Department of Cultural Resources to dispose of records you have scanned, entered into databases, or <br />otherwise duplicated through digital imaging or other conversion to computer or digital environments. This form does not apply to <br />records which have only been microfilmed or photocopied. <br />A completed copy of the "Electronic Records Production Control Self- Warranty" form must be attached. It can be found in the North Carolina <br />Guidelines for Managing Public Records Produced by Information Technology Systems. <br />RECORDS TITLE <br />DESCRIPTION <br />INCLUSIVE <br />DATES <br />NUMBER OF TAPES <br />OR DISKS <br />MICROFILMED? <br />(YES OR NO) <br />RETENTION <br />PERIOD <br />Requested by: <br />Signature Title <br />Approved by: <br />Signature <br />Concurred by: <br />(except as indicated) Signature <br />Date <br />Mayor /Head of Governing Board Date <br />Assistant Records Administrator <br />NC Division of Historical Resources <br />74 <br />F -9 <br />Date <br />Attachment number 1 <br />Page 174 <br />