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West Virginia State Archives

WVAH-05
Form #5

Permission For Use of Photographs and Moving Images
West Virginia Archives and History


Use is: _____ Non-Profit _____ Commercial

Intended use of the image(s):


Images will be used for:

___ Printed publication ___ Exhibition ___ Film ___ DVD
___ Video ___ Broadcast ___ 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 _______________________

Printed Name _________________________________ Title _______________________

Affiliation ________________________________________________________________

Mailing Address ___________________________________________________________

City ______________________________ State ______ Zip Code ___________________


Permission for reproduction by:


___________________________________________ 	Fee Paid $_________
Archives and History


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West Virginia Archives and History