Ames Historical Society

REQUEST FOR REPRODUCTION OF IMAGES

Name: __________________________________________________ Date: ______________

Affiliation: _______________________________________________

Ames Historical Society member:
yes
no

Address: ___________________________________________________

___________________________________________________

Phone:_________________________ Email: ___________________________

Intended use:
personal interest, research, student project

educational program/kit produced by non-profit agency

exhibit at non-profit museum, library, historical agency

print publication

electronic publication

commercial (advertising, merchandise, display)

other

Details of use: __________________________________________________________________

Description and date of image: _____________________________________________________ ______________________________________________________________________________

______________________________________________________________________________

Source of image:
Ames Historical Collection

Ames Tribune Photo Archive (requires written permission for publication and commercial use)

Private collection

Digital reproduction format:

scanning resolution:
300 dpi
600 dpi
other _____

file format:
jpg
tif

delivery method:
email
CD

Charges

Reproduction cost

____ images @ $10 each (includes CD) ______

Use fee (if applicable)

ORDER TOTAL $

………………………………………………….

Staff Use

Permission obtained:
yes
no

Payment:
cash
check
other Received by ______ Date _____________

Processed by _________________ Sent ________