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Intended use of the image(s):
Images will be used for:
___ Printed publication ___ Exhibition ___ Film ___ DVD
___ Video ___ Television ___ Filmstrip ___ CD
___ Private use ___ On-line ___ Other (please specify): ______________________
Description & Fee:
Total Due:
Signature below indicates the attached conditions for the use of image(s) have been read, approved, and agreed to:
Signed ______________________________________ Date ________________________
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City ________________________ State ____ Zip Code _______
Permission for reproduction by:
___________________________________________ Fee Paid $_________
Director, Archives and History