20181002 Agency Loan Request Form Final V6
Agency Loan Request Form
Agency information
|Agency GA: |Date: |
|Agency name: |
|Agency user name: |User ID: |
|Email: |Telephone: |
Service options (select one)
View at Gepps Cross Research Centre (free of charge)
Routine - requests are processed within 48 hours (excluding delivery time)
Urgent - requests are processed within 24 hours (excluding delivery time)
Purpose of loan (please state below)
Refer to State Records’ website for a current list of regulated fees and charges. Longer processing times apply when requesting items held at State Records’ Collinswood repository.
Delivery/collection options (select one)
Send by DX (items weighing 5+kg will incur an additional charge). DX number: ____________
Collect from Gepps Cross
I authorise the following courier to collect the records on my behalf:
|State Records use only |
|Driver signature and ID number: |
Loan details
|No. |Series and Consignment No. |Unit No. (Box or |Record details |
| |(GRS/GRG/MRG) |Vol. No.) |(file number and/or file name/unit date range) |
|1 | | | |
|2 | | | |
|3 | | | |
|4 | | | |
All loans are subject to the conditions of loan.
Please email a copy of the completed form to srsaLoanServices@.au.
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