State Archive in Krakow, Branch

State Archive in Krakow, ...... Branch

Order Number

sign of the case

To be completed by the person submitting the order (PLEASE FILL RELEVANT FIELDS CLEARLY)

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Name and surname or name of institution, full address, phone number, fax number, e-mail address
Please make a reproduction from the following: Collection/No/Pages/Cards* ......
...... Further details of request: ......
Formof reproduction / Number of copies / Form of the reproduction / Number of copies
photocopy/printout* black and white A4 / scan from microfilm
photocopy/printout* black and white A3 / copy of digital version
photocopy/printout* coloured A4 / copy/extract* from a print/typescript*
photocopy/printout* coloured A3 / copy/extract* from a manuscript
photocopy/printout* black and white from the library/archival finding aids* / reports from databases ......
carrier
digital reproduction / other ......
Please authenticate the items requested above
Please give your consent for the publication of the items requestedabove in ………………..
……………………………………………………………………………………………………………………….
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Iam going to collect the reproductions personally/by post*
The fee for the service will be in cash/by bank transfer*
I am acquainted with the Regulations and Price List for Services; I have been informed of the total cost of this order and the necessity to pay within 14 days. In the event of failure to pay within this time limit, the order will be canceled.
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Signature of the person accepting the order Date and signature of the person submitting the order
To be filled in by the person accepting and supervising the order
authentication / exempt/not subject to stamp duty *
amount of the stamp duty ......
Remarks:
Form of reproduction / Number of copies / Price / Value / Made / Value
photocopy/printout* black and white A4
photocopy/printout* black and white A3
photocopy/printout* coloured A4
photocopy/printout* coloured A3
photocopyblack and white – library/archival finding aids*
digital reproduction (scan or a digital photograph)
scan from microfilm
copy of digital version
copy/extract* from a print/typescript*
copy/extract* from a manuscript
reports from databases– printout
reports from databases – transmission/recording on a carrier*
carrier
other......
postage fees
Total
Evaluated by and customer informed by: ......
Date and signature/s
Approved by: ......
Date and signature
Payment verified by: ......
Date and signature
To be filled in by the person submitting the order / Filled in by the Archive
Confirmation of receipt of the order
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Date and signature / Sent by:
post......
Date and signature
e-mail ......
Date and signature

*delete as appropriate