UNIVERSITY OF PENNSYLVANIA RECORDS CENTER

Mezzanine 4015 Walnut St.
Philadelphia, PA 19104-6198
(215) 898-9432
Interfile / Refile  Request 
PERSON MAKING REQUEST  
Date:

	
Name of Individual Making Request:

	
Customer Number:

	
Phone Number:

	

Hospital/Office/School:

	
Department/Division:

	

INFORMATION ON REFILE
[   ] URC Courier     [   ] Own Courier
File Title	
Department Box Number 	
URC Use Only	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	
SCHEDULING CONFIRMATION
Deliver to:

	
Ask for:

	
Phone Number: 

	

Special Instructions:

	
Date Requested By:

	
Dispatcher:

	

TRANSACTION CONFIRMATION

	

	

	

	

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TITLE	
DATE	
TIME