Description of records to be copied (continues overleaf)
Series No., File No. 	Details / Page or folio no.	Instructions: Section of page, and / or description, colour or B&W	
Resolution	No. of images 	Cost
GST inclusive	

						

						

						
						
Total						
Requested by
Name		
Postal address		
Phone		
Email		
I request the listed items for the purpose of research  study  for publication. 
I undertake that I will not use any copies supplied to me for any purpose, other than the purpose specified above.
I understand that no copies may be published or reproduced in any format without the written consent of Archives ACT.
I have completed and attached a request for permission to publish order form
I hereby declare that I will adhere to the Copyright Act 1968 in relation to the use of these items.
Signature
	
Your personal information will only be used for the purpose for which it was collected. Fuller details of the Territory Records Office’s Privacy Policy can be viewed at: http://www.territoryrecords.act.gov.au/legal/privacystatement
Collection of completed copying
Please post to the address above		
Please email to the address above		
Hold for collection and phone me on the no. above when copies are ready 		

Description of records to be copied (continued)
Series No., File No. 	Details / Page or folio no.	Instructions: Section of page, and / or description, colour or B&W	
Resolution	No. of images 	Cost
GST inclusive	

						

						

						

						

						

						

						

						
Total						

Archives ACT Use Only
Date of request		Number of copies @		
Date completed		Standard postage $4.55		
Records dispatched for copying to:		Date		
Order received		Total		
Date contacted				
Date sent/collected		Receipt no.