UNIVERSITY OF PENNSYLVANIA RECORDS CENTER

Mezzanine 4015 Walnut St.
Philadelphia, PA 19104-6198
(215) 898-9432

RECORDS TRANSFER REQUEST  
PERSON MAKING REQUEST  
Date:

	
Name of Individual Making Request:

	
Customer Number:

	
Phone Number:

	

Hospital/Office/School:

	
Department/Division:

	

TRANSACTION CONFIRMATION

	

	

	

	

SIGNATURE	
TITLE	
DATE	
TIME	

INFORMATION ON TRANSFERS
[   ] URC Courier     [   ] Own Courier
Department
Box Number	
Description of Box Contents
(Title, Range, Inclusive Dates) 	
Disposition 
Date