|
Date: ______/______/______
(month / day / year) |
|
| Receipt No.: _________________________________ | Amount Received: _________________________ |
| P.O. #: ___________________ | Amount Due: _____________________ |
| (Credit Card Information, see reverse) | Staff Initials: _____________ |
|
Type:
_________________________________________________________________
[C=Copy; F=File; N=Nothing found; O = Other (TA, etc); R=Research; S=Certified copy] |
|
Shipping Code:
_________________________________________________________
[C=Courier; F=Fax: M=Mail; P=Phone; U==UPS; X=Fedex] |
|
Source:
________________________________________________________________
[F=Fax; M=Mail/courier; P=Phone; S=Searchroom; E=Email; L=Lobby] |
Last Name: __________________________________ First Name: ____________________________ User ID: ________________
Organization: ________________________________________________________________________________________
Street Address: _______________________________________________________________________________________
City/State: __________________________________________________________ Zip: _________________________
Phone: ________________________________________ Fax: ______________________________________________
Billing address if different from above:
Organization: _________________________________________________________________________ User ID: _________________
Street Address: _________________________________________________________________________________________
City/State: _______________________________________________________ Zip: _____________________________
Phone: __________________________________________ Fax: ______________________________________________
Agent's Name: _________________________________________________________________________________________
Agent's Signature: ______________________________________________________________________________________
Credit Card No.: ________________________________________________________________
MC / VISA / DISC
Expiration Date: _________________ V Code.: ________________________________
RECORD DESCRIPTION
Series No.: __________________ Series Name__________________________________________
Name/Title, etc. (from document): ______________________________________________________
Date: ____________Box:/Volume: _________MdHR______________ File #/ Page/s: _______________________
Location ________________________________________________
Comments __________________________________________________________________________________________
___________________________________________________________________________________________________
Name/Title, etc. (from document): ______________________________________________________
Date: ____________Box:/Volume: __________MdHR______________ File#/ Page/s: _______________________
Location ________________________________________________
Comments __________________________________________________________________________________________
___________________________________________________________________________________________________
Name/Title, etc. (from document): ______________________________________________________
Date: ____________Box:/Volume: ___________MdHR______________ File#/ Page/s: _______________________
Location ________________________________________________
Comments __________________________________________________________________________________________
___________________________________________________________________________________________________
Name/Title, etc. (from document): ______________________________________________________
Date: ____________Box:/Volume: ________MdHR________________ File#/ Page/s: _______________________
Location ________________________________________________
Comments __________________________________________________________________________________________
___________________________________________________________________________________________________