MARYLAND
STATE ARCHIVES
IMAGE REQUEST
AND
REPRODUCTION
PERMISSION FORM
All requests for documents,
images and permission to reproduce items for publication, commercial
use, or any purpose from the Maryland State Archives and the Maryland
Commission on Artistic Property must be made in writing. In order to
process your request we need to determine the type of imaging and reproduction
rights and fees that are involved. Please complete this form in as much
detail as possible and return it via fax, post mail, or e-mail. Incomplete
information will delay your order. Requests will be completed within
2-4 weeks after payment is received.
Permission for reproduction
rights is given on a case-by-case basis at the sole discretion of the
Maryland State Archives and the Maryland Commission on Artistic Property.
Please see the Archives’
website for a list of fees and services for permissions. This form must
be sent in with the Payment Form for Images and Rights & Reproductions
requests. All orders must be prepaid.
Contact Information:
Name: ___________________________________________________________________________
Organization: ______________________________________________________________________
Address: __________________________________________________________________________
City/State/Zip: _____________________________________________________________________
Country: _________________________
Phone: _________________
Fax: __________________ E-mail: _______________________
Date of Order: ________________
Images or Documents Requested
(attach separate sheet if necessary)
1.
Artist/Author: __________________________________
Accession # __________________
Title: ______________________________________________________________
Medium:
___________________________________________________________
2.
Artist/Author: __________________________________ Accession
# ___________________
Title: ______________________________________________________________
Medium: ________________________
3. Artist/Author:
__________________________________ Accession # ___________________
Title: ______________________________________________________________
Reproduction Use Information:
Purpose of Photography/
Image request:
(Please check any/all that
apply)
[ ] Non-Profit[
] Commercial [ ] School or University
project
[ ] Personal Use
[ ] Exhibition [ ] Other: _________________________________
Format:
Check all that apply
[ ] Black & white
print: size 8 x 10 [ ] 11 x 14 [ ] 13 x 19 [ ] Other_______
[ ] Color print: size
8 x 10 [ ] 11 x 14 [ ] 13 x 19 [ ] Other_______
[ ] Color transparency
(3 month rental based on availability)
[ ] Digital File (see
digital format page)
Print Publication:
Publication type:
[ ] Book [ ] Journal/Magazine [
] Exhibition catalog [ ] Thesis/Dissertation
[ ] Exhibit panel [ ] Other: ____________
Title/Article: _________________________________________________________________________
Author: _____________________________________________________________________________
Publisher: ___________________________________________________________________________
Distribution: [ ] North
America [ ] Europe [ ] Worldwide
Language(s): ________________________________________________________________________
Print Run _____________________________
Publication Date: ____________________________
Image Location:
[ ] exterior [ ] interior [ ] other: ____________________
Moving Images:
Project type:
[ ] Television [ ] Motion Picture [ ]
Documentary [ ] Video [ ] Other: __________
Title: _________________________________________________________________________________
Producer: ______________________________________________________________________________
Director: _____________________________________________________________________________
Language(s): ________________________________________________________________________
Release/Air Date: ____________________________
Exhibition:
Title: _________________________________________________________________________________
Institution/Location:
______________________________________________________________________________________
Dates: ___________________________
Type of use (ie. exhibition
label, catalogue): ______________________________________________
Exhibition type: Temporary
[ ] Permanent [ ]
Will this image be used in
other formats (catalogue, digital media, and/or promotional materials?
If yes, fill out other applicable sections: ___________________________________________________________________________
Digital Media:
Project type:
[ ] Website [ ] CD-ROM [ ] DVD [ ] Audio
[ ] Other_____________
Title: _________________________________________________________________________________
Producer/ Web-Master: ___________________________________________________________________
Web Address/URL: _________________________________________________________________
Digital Image Request:
File type:[ ] RGB[
] CMYK[ ] Grayscale
[
] jpg [ ] tif[ ] pdf
Resolution: [ ] 300 DPI
[ ] 600 DPI [ ] Other: ____________________
Image Output:H: __________
W___________________
[ ] inches
[ ] pixels
Delivery Method: [ ]
E-mail - $25 per image
Note: E-mail
delivery only covers 1-2 images, totaling no more than 10 MB.
If images cannot be sent via email, an additional $50 charge will be
assessed to furnish the images to a CD-ROM
[ ] CD-ROM - $75
Note: CD-ROM
should be selected for files over 10 MB, or if more than two images
are ordered
Terms and Conditions:
Requests:
All requests to reproduce documents, images and photographs from the
collections of the Maryland State Archives and the Maryland Commission
on Artistic Property must be submitted on this application. The applicant
agrees to abide by all terms, conditions and provisions of this agreement.
Non-profit:
The Maryland State Archives and the Commission on Artistic Property
are pleased to support the missions of non-profit organizations by providing
fees at a reduced rate. In order to qualify for the non-profit fee schedule,
those organizations must be able to prove legal not-for-profit status
by providing proper documentation such as tax-exempt certificates or
letters of identification.
Fees:
Prepayment of all fees, including use fees, is required before permission
is granted. If the size of the edition, language rights, medium
or image location exceeds the terms specified in this application, the
applicant shall immediately pay the difference in use fees.
Permissions:
Permission for reproduction is limited to the applicant for a one-time
nontransferable use in a single format. Any subsequent use is subject
to additional fees.
Courtesy copy:
One complimentary copy of any published work, including CD-ROM products,
in which the image appears must be provided to the Maryland State Archives
or the Maryland Commission on Artistic Property.
Image manipulation:
The Maryland State Archives’ primary interest is to maintain the integrity
of the original image. Reproductions in any media may not be altered,
cropped, bled or overprinted, and nothing may be superimposed on a reproduction,
unless agreed upon in advance by the Maryland State Archives and/or
the Maryland Commission on Artistic Property.
Credit Line:
Credit Line should indicate where appropriate Courtesy of the Maryland
State Archives or Courtesy of the Maryland Commission on Artistic Property
of the Maryland State Archives.
Copyright:
In addition to the permission of the Maryland State Archives or the
Maryland Commission on Artistic Property, additional permissions may
be required. Those permissions may include, but are not limited to:
Copyright: In cases of works by living artists or and/or subject to
the 1976 Copyright Law or the 1991 Visual Artists Rights Act, written
permission must be secured by the applicant from the artist, his/her
agent, or the copyright owner and provided to the Archives before a
photograph/image of the artwork will be released.
Signature:
Permission for reproduction is granted only when this application is
countersigned by a representative of the Maryland State Archives or
the Maryland Commission on Artistic Property.
____________________________________________
_______________
Signature
Date
Electronic Signature:
[ ] By typing
my name above and checking this box in lieu of my signature, I accept
personally the conditions of this contract set forth above. Date____________
When signed by a representative
of the Maryland State Archives, this form constitutes permission for
reproduction as outlined above.
Request is [ ]
Approved [ ] Not Approved
____________________________________________
_________________
Signature
Date
Email, fax or mail request
to:
Maryland State Archives
350 Rowe Boulevard
Annapolis, MD 21401
Phone: 410-260-6400 / MD toll free: 800-235-4045 / tty: 800-735-2258
Fax: 410-974-3895
permission@mdsa.net