West Virginia Archives and History

Form #2

Specialized Collections Use Form
West Virginia Archives and History

Name ___________________________________________________________________________________

Affiliation ________________________________________________________________________________

Street Address ____________________________________________________________________________

City _____________________________________________ State ________ Zip _______________________

Home Phone ________________________________ Business Phone ________________________________

E-Mail Address (optional) __________________________________________________

Purpose of Research (check all that apply)

____01 State agency operations ____02 Legislation
____03 Genealogy ____04 Military history
____05 Student paper ____06 Graduate thesis
____07 Community history ____08 Historic preservation
____09 Archaeology ____10 Printed publication
____11 Illustrations ____12 Legal proceedings
____13 Property title search ____14 Exhibit
____15 Instructional use ____16 Audiovisual Archives
____17 Other (please specify): ____________________________________________________

DECLARATION: I acknowledge that I have received, read, understand and will abide by the Archives and History Library rules as listed. I understand that violation of the rules is grounds for revocation of permission to use the library or Archives and History materials. For any publication, broadcast, film, exhibition, etc., in which this material is used, I will give credit as follows: "West Virginia State Archives." When a specific collection name is provided by Archives and History, that name will also appear in the credit line.

Signature                                                                                          Date

Services and Fee Guidelines

West Virginia Archives and History