Pictorial Permission & Photographic Services Order Form
Printed Name: ____________________________________________________Telephone_________________
Organization or Company Name:_______________________________________________________________
Address:____________________________________________________________________________________
E-mail address:_____________________________________________________________________________
Method of delivery: ________________US Mail _________________Email _______________ Pick-up
Description of publishing project:
Author(s)/creator(s):_________________________________________________________________
Description or title of project_______________________________________________________
Publisher or sponsor:_________________________________________________________________
Place of publication or project:______________________________________________________
Date of publication or use: ___________________Estimated print run:___________________
Economic classification of project:
[ ] Commercial [ ] Non-profit, government, scholarly, small press
Nature of project:
[ ] Book [ ] Article [ ] Unpublished paper [ ] Worldwide, multi-media
[ ] Other non-editorial (calendars, cards, book covers, ads, etc.) [ ] Film, Video, Television
[ ] CD/DVD [ ] Website [ ] Exhibition [ ] Add'l use, re-use,specify:
Statement of responsibility: I certify that the information on this form is correct and I accept the conditions of use. I am authorized to enter into this agreement on behalf of the above named organization.
Signature of Applicant:__________________________________________________Date:________________
Paid by cash, check (number)_____________________ Payment received by: __________________
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