ROLE DESIGNATION FORM - Louisiana
Louisiana State Archives ? Records Management Louisiana Secretary of State P.O. Box 94125 Baton Rouge, LA 70804-9125 recmgt@sos.
SSARC-941 (09/2020)
ROLE DESIGNATION FORM
Date Received:
Archives Use Only Date Entered:
Entered by:
Instructions: Use this form to designate individuals to assist your agency's Records Officer. This form does not need to be signed by the Chief Executive / Head of Agency. It may be signed by the Records Officer, Section Supervisors or Directors. Please do NOT use this form to designate your agency's Records Officer (use form SSARC-940 to do so).
Please print or type all information below:
1. Agency: _______________________________________________________________________
2. Agency Mailing Address: __________________________________________________________
3. Designee's Role (Check all that apply):
Records Center Coordinator
Legal Contact
Records Coordinator
Information Technology Contact
4. Designee Section/Office Representing:______________________________________________
5. Designee Name: _________________________________________________________________
6. Designee's Title: _________________________________________________________________
7. Designee's E-mail Address: ________________________________________________________
8. Designee's Phone: (_____) _______________9. Designee's Fax: (_____) ___________________
The person listed above is appointed as the coordinator/contact for the section indicated. If our coordinator/contact changes, we will notify the State Archives of the change within thirty days of such change.
________________________________________________________________________________
Submitter's Name
Title
Date
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