Filled in by the Archive:
ARCHIVAL RESOURCE USER REQUEST FORMULA
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(based on annex No. 1 to the regulation No. 4 of the Head Director of the State Archives, from the 18 th May 2000,
modified by the regulation No. 15, from the 22nd December 2011)
 N
 G
 W
 S
 P
 I
Information concerning occupation and the academic/professional titles (fields marked in gray) is not mandatory, and serves merely to aid the analysis of users of the
archive. Such omissions will not result in any limitation to the rights of the user to use the archival resource. Also, the submission of a subject or title of any work that uses a document or part of a document is voluntary, except in cases in which information is legally required. Other information is collected for the purposes indicated in
Article No 23, paragraph 1, point 2 and 4 from the Law of the 29th August 1997 pertaining to Personal Data Protection. On the expiry of the usefulness of any of the
above voluntary information used to aid the management of archival collection sharing, such information will not be processed in databases. Information about the supervisor of the archival collection user, or about the recommending person, must be supplied if the users do not apply on their own behalf, or if they refer to a third party
(out of their own will or at the explicit request of the State Archive). With regard to the part of the archival collection where availability is legally restricted due to personal
data or the titles to property, it is required from the users to prove that they have the authority to have access to such content, or to submit a formal power of attorney.
PERSONAL INFORMATION OF THE ARCHIVAL COLLECTION USER
Name and surname
e-mail
Permanent address
telephone
Address for correspondence
in Poland during the
use of archival collection
(supply if different from the permanent address)
type and number of ID
accademic or
professional title
occupation
person (institution) who commissioned the
user or which(who) gave a recommendation to conduct archival research
 commission
 recommendation
 power of attorney
(name and address of the institution, or the name, surname and address / place of work)
INFORMATION ON ARCHIVAL RESEARCH
subject/title of the work
(scope of research)
Nature of the intended archival research:
 scholarly,
 genealogical,
 prioprietary,
 media,
 social benefits,
 other – what kind?.........................................................................................................................................................................................................................................
chronological scope
of research
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numbers and names of
archival collections included in the application
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if necessary continued on the next page 
I am acquianted with the Terms and Regulations of the use of archival materials in the reading rooms of the State Archive in
Krakow and I undertake to apply the provisions contained therein.
date
signature
on the reverse – additional declarations by the user, if legally required due to the content of the archival materials
STATEMENT - GENEALOGICAL RESEARCH
(To be filled in if applicable)
I hereby declare that I am conducting a private genealogical research concerning my own family members. In relation to the individuals whose data I am looking for, I remain in the following degrees of kinship:
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(Please specify the degree of kinship)
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date
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signature
DECLARATION – PROTECTION OF PERSONAL RIGHTS AND PERSONAL DATA
I hereby certify that any information, concerning an individual or individuals, included in the archival material made available to me,
which may seem still to be valid in any way, will be used in accordance with the purpose specified in the statement on the reverse
of this page. Such information will also not be used in any manner that violates the rights and freedoms of any citizen, which stem
in particular from the regulations protecting personal rights and personal data.
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date
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signature
 numbers and names of archival collections included in the application – continued from previous page
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ARCHIVAL NOTES
No objections:
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signature of the Department Head
Other comments: