Image Reproduction request 

|Name of Requester: *

|Position:

|Institution

>(If this is not an individual request, the full legal name of the organization is required - should include Inc., Corp. or Ltd):

|Mailing Address: *

|Telephone Number:
(xxx) xxx-xxxx *

|Fax Number:
(xxx) xxx-xxxx

|Email Address: *

|Image(s) requested: *

>Please be as specific as possible. If you know the name of the image or the call number, include it. If not, describe the image or type of image you are looking for.

|Format and resolution required: *

|Project Type:

>

|Full legal name of publisher or producer (i.e. including Inc., Ltd., Corp.) *: *

|Title of work: *

|Language: *

|Print run: *

|Expected publication date: *

|Project description: *

>Include details regarding the type of project (i.e. exhibit, book) and the nature of your intended use, its relevance to Hbc and information about your organization if applicable.

|Caption to accompany image and text mentioning or relating to image and, where not otherwise obvious, context in or around which image will be used: *

|Other Uses (i.e. Website, catalogue):

|Profit or non-profit organization: *

|Deadline for image: *

|Signing authority: *

>(name to address permission letter for signature; include title or position if different from requester)

|Additional comments: