Please use the form below to request permission to reproduce materials owned the Chatham Historical Society.
Please review the Society's Collection Use and Photocopy Policy and Fees.
on this page below; or view/download/print a PDF version of this form in a new window.
APPLICATION FOR PERMISSION TO REPRODUCE ANY MATERIALS
OWNED BY THE CHATHAM HISTORICAL SOCIETY
OWNED BY THE CHATHAM HISTORICAL SOCIETY
Please complete all applicable sections of this form and return to the Chatham Historical Society, P.O. Box 709, Chatham, MA 02633. A countersigned copy of this form will be returned to you 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:
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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 January 19, 2008.