Use is: _____ Non-Profit _____ Commercial
Intended use of the image(s):
Images will be used for:
| ___ Printed/electronic publication | ___ Exhibition | ___ Film | ___ DVD |
| ___ Video | ___ Broadcast | ___ CD | |
| ___ Private use | ___ On-line | ___ Other | (please specify): ________________________________________ |
Description & Fee:
Total Due:
Signature below indicates the attached conditions for the use of image(s) have been read, approved, and agreed to:
Signed ______________________________________ Date _______________________
Printed Name _________________________________ Title _______________________
Affiliation ________________________________________________________________
Mailing Address ___________________________________________________________
City ______________________________ State ______ Zip Code ___________________
E-Mail ___________________________________ Telephone _____________________
Permission for reproduction by:
___________________________________________ Fee Paid $_________