APPLICATION FOR PERMISSION TO REPRODUCE PHOTOGRAPHS

 

Please complete this form and return it to the Chatham Historical Society, P.O. Box 381, Chatham, MA 02633. A countersigned copy of this form will be returned when permission has been granted.

Applicant: _______________________________________________________________

 

Address: ________________________________________________________________

 

Telephone__________________________Fax: _________________________________

 

E-Mail Address______________________________________

 

Applies for permission to reproduce:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

 

For the following publication      OR                  Other use (describe)

 

Title: _______________________________________________________________

Author or Editor: ______________________________________________________

Periodical name (if applicable): ____________________________________________

Publisher and address: __________________________________________________

Expected date of publication:______________________________________________

 

Circle all that apply regarding publication or exhibition:

Non-profit   Commercial   University Press   Book   Textbook   Periodical  

Exhibition catalog   Dissertation

Other (describe) ______________________________________________________

 

Circle all that apply regarding the reproduction:  Color   Black and white   Cover   Double-page  Full Page (8x10 or larger)   Half page    Quarter Page.

 

Rights:  One time, English use.  Credit line must read:  Courtesy, The Chatham (MA) Historical Society.

 

If granted permission for the uses above, I agree to abide by the provisions as stated in the Society’s Collection Use and Photocopy Policy and Fees.

 

Signature of applicant ___________________________________Date____________

Signature for CHS _____________________________________Date____________

                                                            (Title)

 

Form approved by the executive board of The Chatham Historical Society at its meeting on February 12, 2002.