Special Media Archives Services Division (NWCS) **Item Approval Request
List** OMB No.: 3095-0025

National Archives and Records Administration Expires: 09/30/2010

Room 3360 Telephone: 301-837-1970

8601 Adelphi Road Facsimile: 301-837-3620

College Park, MD 20740-6001 E-Mail: <mopix@nara.gov>

  --------------------- ----------- ----------- ---------- -------- ----------- ----------------------
  **A.                                                                          
  Customer/Researcher                                                           
  Information**                                                                 

  Customer                                                          Date        
  Name/Preferred                                                    Submitted   
  Contact                                                                       

  Company Name                                                                  

  Street Address                                                                

  City                              State       Zip                             Country
                                                /Mailing                        
                                                Code                            

  Telephone             Facsimile                          E-Mail               
                        (FAX)                                                   
  --------------------- ----------- ----------- ---------- -------- ----------- ----------------------

<table>
<colgroup>
<col style="width: 29%" />
<col style="width: 21%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 9%" />
<col style="width: 6%" />
<col style="width: 10%" />
<col style="width: 5%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="10"><strong>B. INSTRUCTIONS:</strong> Complete boxes B1,
B2, and B3. We cannot “approve” incomplete listings.
<strong>NOTE</strong>: “Pending” codes<strong>:
“I”</strong>=Intermediate exists; <strong>“P”</strong>= no intermediate;
<strong>“2”</strong> = requires written permission from donor, donor’s
representative, or copyright, or copyright holder’s representative to
reproduce.</td>
</tr>
<tr class="even">
<td><p><strong>1. Control and reel number</strong></p>
<p><strong>(Each reel must be on a separate line)</strong></p></td>
<td><strong>2. Title/Subject</strong></td>
<td><p><strong>16</strong></p>
<p><strong>mm</strong></p></td>
<td><strong>35 mm</strong></td>
<td><strong>VT</strong></td>
<td><strong>Archival Format</strong></td>
<td><p><strong>Running</strong></p>
<p><strong>Time</strong></p></td>
<td><p><strong>3. Order</strong></p>
<p><strong>Copy Format</strong></p></td>
<td colspan="2"><p><strong>Approval</strong></p>
<p><strong>And</strong></p>
<p><strong>Pending Codes</strong></p></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

NA FORM 14110 (5-04)

**PAPERWORK REDUCTION ACT PUBLIC BURDER STATEMENT**

You are not required to provide the information requested on a form that
is subject to the Paperwork Reduction Act unless the form displays a
valid OMB control number. Public burden reporting for this collection of
information is estimated to be 15 minutes per response. Send comments
regarding the burden estimate or any other aspect of the collection of
information, including suggestions for reducing this burden, to National
Archives and Records Administration (NHP), 8601 Adelphi Road, College
Park, MD 20741-6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. SEND
COMPLETED CORM TO THE ADDRESS AT THE TOP OF THE FORM.

> **PRIVACY ACT STATEMENT**

Sections 2104(a) and 2108 of Title 44 of the U.S. Code authorize the
collection of this information. The primary use of this information is
by NARA staff to process and track your reproduction request and to
provide information to you and the vendor you select to make your
reproduction. The information may also be used to facilitate preparation
of statistical and other reports. Furnishing the information requested
on this form is voluntary, but failure to do so will prevent NARA
processing your reproduction request.

NA FORM 14110 (5-04)

**CONTINUATION SHEET**

**ITEM APPROVAL REQUEST LIST**

  ----------------------------------- -------------- ------------------------------
  **Name/Company Name**               **Order        **Page
                                      Number**       \_\_\_\_\_\_of\_\_\_\_\_\_**

  ----------------------------------- -------------- ------------------------------

<table>
<colgroup>
<col style="width: 29%" />
<col style="width: 20%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 9%" />
<col style="width: 7%" />
<col style="width: 10%" />
<col style="width: 5%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="10"><strong>B. INSTRUCTIONS:</strong> Complete boxes B1,
B2, and B3. We cannot “approve” incomplete listings.
<strong>NOTE</strong>: “Pending” codes<strong>:
“I”</strong>=Intermediate exists; <strong>“P”</strong>= no intermediate;
<strong>“2”</strong> = requires written permission from donor, donor’s
representative, or copyright, or copyright holder’s representative to
reproduce.</td>
</tr>
<tr class="even">
<td><strong>1. Control and reel number</strong></td>
<td><strong>2. Title/Subject</strong></td>
<td><p><strong>16</strong></p>
<p><strong>mm</strong></p></td>
<td><strong>35 mm</strong></td>
<td><strong>VT</strong></td>
<td><strong>Archival Format</strong></td>
<td><p><strong>Running</strong></p>
<p><strong>Time</strong></p></td>
<td><strong>3. Order Copy Format</strong></td>
<td colspan="2"><p><strong>Approval</strong></p>
<p><strong>and</strong></p>
<p><strong>Pending Codes</strong></p></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
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<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
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<td></td>
<td></td>
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<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
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<td></td>
<td></td>
<td></td>
<td></td>
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<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

NA FORM 14110 (5-04)