_____ 35mm Color Slide

_____ 4" x 5" Color Transparency

_____ 35mm Negative

_____ 5" x 7" print____(b&w) or____(color)

_____ Digital Image _______ (format) _______ (dpi)

_____ VHS Videotape

_____ Beta SP Videotape

_____ Audio Cassette Tape

Reproduction will be published or exhibited in: ______________________________________________________

Issue: ___________________________________

Publication Date (if applicable):________________

Scope of Permission (one time only use): _________ (North American Rights) or ________ (Worldwide Rights)

Requested By _________________________________ Date__________________

Mailing Address ______________________________________________________

Email Address _______________________________________________________

Phone No. __________________________________________________________

Publisher: ___________________________________________________________

Address: ___________________________________________________________

Phone: ____________________________ Fax: _____________________________

Use Fee: [See fee schedule on bottom of form]
Prepayment required. Make check payable to Kentucky Library and Museum

Signature ___________________________________________________________
(The above signature verifies that the signatory has read and agrees to the conditions listed on this form.)

NOTICE:
Warning Concerning Copyright Restrictions

The copyright law of the United States (Title 17, United States Code) governs the making of photocopies or other reproductions of copyrighted material. Under certain conditions specified in the law, libraries and archives are authorized to furnish a photocopy or other reproduction. One of the specified conditions is that the photocopy or reproduction is not to be "used for any purpose other than private study, scholarship, or research." If a user makes a request for, or later uses, a photocopy or reproduction for purposes in excess of "fair use," that user may be liable for copyright infringement.

I understand that the responsibility for obtaining permission to publish this image is my responsibility and that Western Kentucky University is not responsible for any copyright infringement. Citations must identify the item and/or name of the collection followed by: Kentucky Library and Museum, Western Kentucky University, Bowling Green, Ky. In some cases the Kentucky Library and Museum staff will request a copy of the publication. An additional fee applies when images and artifacts are used for commercial or non-commercial purposes such as publication in books, magazines, videos, exhibits, etc.

Fee Schedule:
Non-Commercial 25.00
Commercial 100.00

Other Uses: contact us

Original photography may require work by an out-of-house photography studio. An estimate of the cost of such work is available upon request. Please note the studio may bill the fee directly to the requesting party.

Publication quality negatives, transparencies, etc., produced to fill such a request remain the property of the Kentucky Library and Museum, and, if loaned, must be returned to the Kentucky Library and Museum at the end of the agreed upon rental period ______________________________. The borrower is liable for the cost of replacing any image lost or damaged during the rental period.

Form last modified 7/30/ 2003