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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