Form 14110 Item Approval Request List

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

National Archives and Records Administration Expiration date: XX/XX/20XX

Room 3360 Telephone: 301-837-1970

8601 Adelphi Road Facsimile: 301-837-3620

College Park, MD 20740-6001 E-Mail: mopix@nara.gov

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. Local identifier & reel number (FILMS MUST BE IN NUMERICAL SEQUENCE / EACH REEL MUST BE ON A SEPARATE LINE)	2. Title/Subject	16 mm	35 mm	VT	Archival Format (that NARA will provide to vendor)	Running Time	3. Customer Copy Format (e.g. betasp, digibeta, dvcam, HD, digital video files, etc.)	Approval And Pending Codes
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     

PAPERWORK REDUCTION ACT PUBLIC 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 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 2109, 2116(c) and 2307 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.

CONTINUATION SHEET

ITEM APPROVAL REQUEST LIST

Name/Company Name      

Order Number      

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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. Local Identifier & reel number (FILMS MUST BE IN NUMERICAL SEQUENCE / EACH REEL MUST BE ON A SEPARATE LINE)	2. Title/Subject	16 mm	35 mm	VT	Archival Format that NARA will provide to vendor)	Running Time	3. Customer Copy Format(e.g. betasp, digibeta, dvcam, HD, digital video files, etc.)	Approval and Pending Codes
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     
     	     	     	     	     	     	     	     	     	     

National Archives and Records Administration NA FORM 14110 (07-10)