"Order Form / Invoice" - Mississippi

Order Form / Invoice is a legal document that was released by the Mississippi Department of Archives and History - a government authority operating within Mississippi.

Form Details:

  • Released on October 1, 2015;
  • The latest edition currently provided by the Mississippi Department of Archives and History;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Mississippi Department of Archives and History.

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O R D E R F O R M / I N V O I C E
Order No. ___________
Mississippi Department of Archives and History
Archives & Records Services Division, P.O. Box 571, Jackson, MS 39205-0571
mdah.ms.gov, Phone 601-576-6850, Fax 601-576-6964
Name:
Business: _________________________________________
The user must assume responsibility for compliance with federal copyright law (Title 17, U.S. Code, and Title IV, Digital
Millennium Copyright Act, in accordance with the Berne Convention for the Protection of Literary and Artistic Works) and any other
requirements involved in the use of the item(s) listed (see Notice on the reverse of this sheet before signing). Internet and all electronic
publishing or display is subject to copyright law.
I request single copies of the material listed on this form and the related attachments and agree to handle them in accordance with
the Department’s conditions as specified. I have been advised of the obligation to observe copyright and promise to make only “fair
use” of these copies in my private study, scholarship, and research. I will accept full responsibility for any infringement of copyright or
other legal questions that may arise from the making of these copies or any later use of them.
*S
*
Patron’s Signature
Date
R
L
I
EE
EVERSE TO
IST
TEMS
Quantity
Photocopies & Microform Prints
_____
Photocopies
$0.25 per page
$
@
_____
Photocopies requiring Special Handling
$0.50 per page
$
@
_____
Photocopies requiring Certification
$0.75 per page
$
@
_____
Photocopies requiring Special Handling and Certification
$1.00 per page
$
@
_____
Microform prints
$0.50 per page
$
@
_____
Microform prints requiring Certification
1.00 per page
$
@
(an original between 12”x17” and 35”x50” is an oversize item (OSI))
Digital Images
_____
600 ppi
$5.00 per image
$
TIFF
@
_____
600 ppi
requiring Special Handling or Expedited Service
$10.00 per image
$
TIFF
@
_____
600 ppi
requiring Special Handling and Expedited Service
$15.00 per image
$
TIFF
@
_____
300 ppi
of an OSI
$25.00 per image
$
TIFF
@
_____
300 ppi
of an OSI requiring Special Handling or Expedited Service
$50.00 per image
$
TIFF
@
_____
300 ppi
of an OSI requiring Special Handling and Expedited Service
$75.00 per image
$
TIFF
@
Audio or Video Copies
Audio
Video-Reference
Video-Production-quality
For MDAH use only
_____
Hours of production time
$40.00 per hour
$
@
_____
Hours of production time including Expedited Service
$80.00 per hour
$
@
Service charges are in addition to the charges listed above.
Services
_____
Outside Vendor Delivery and Return (quotation required, $40.00 per round trip)
$
_____
$40.00 per hour
$
@
Staff Oversight
_____
Use Fees (quotation and written agreement required)
$
_____
$
Other:
S
$
UBTOTAL
0.00
*P
A
R
*
AYMENT IN
DVANCE IS
EQUIRED
Make checks payable to:
$
Delivery to Patron
(Per quotation OR $3 by U.S. Mail OR $8 by electronic transfer)
MDAH, Archives & Records Services Division
T
D
$
OTAL
UE
0.00
For MDAH use only
Use Permission Completed
OR
MDAH, A&RS Div. Publication Permission Form
Formal A&RS Div. use agreement
Material checked for Restrictions Staff: ________
Date: ____________
AV Agreement No.
D
P
ATE
AID
-OVER-
(Order Form/Invoice, Rev. 10/2015)
O R D E R F O R M / I N V O I C E
Order No. ___________
Mississippi Department of Archives and History
Archives & Records Services Division, P.O. Box 571, Jackson, MS 39205-0571
mdah.ms.gov, Phone 601-576-6850, Fax 601-576-6964
Name:
Business: _________________________________________
The user must assume responsibility for compliance with federal copyright law (Title 17, U.S. Code, and Title IV, Digital
Millennium Copyright Act, in accordance with the Berne Convention for the Protection of Literary and Artistic Works) and any other
requirements involved in the use of the item(s) listed (see Notice on the reverse of this sheet before signing). Internet and all electronic
publishing or display is subject to copyright law.
I request single copies of the material listed on this form and the related attachments and agree to handle them in accordance with
the Department’s conditions as specified. I have been advised of the obligation to observe copyright and promise to make only “fair
use” of these copies in my private study, scholarship, and research. I will accept full responsibility for any infringement of copyright or
other legal questions that may arise from the making of these copies or any later use of them.
*S
*
Patron’s Signature
Date
R
L
I
EE
EVERSE TO
IST
TEMS
Quantity
Photocopies & Microform Prints
_____
Photocopies
$0.25 per page
$
@
_____
Photocopies requiring Special Handling
$0.50 per page
$
@
_____
Photocopies requiring Certification
$0.75 per page
$
@
_____
Photocopies requiring Special Handling and Certification
$1.00 per page
$
@
_____
Microform prints
$0.50 per page
$
@
_____
Microform prints requiring Certification
1.00 per page
$
@
(an original between 12”x17” and 35”x50” is an oversize item (OSI))
Digital Images
_____
600 ppi
$5.00 per image
$
TIFF
@
_____
600 ppi
requiring Special Handling or Expedited Service
$10.00 per image
$
TIFF
@
_____
600 ppi
requiring Special Handling and Expedited Service
$15.00 per image
$
TIFF
@
_____
300 ppi
of an OSI
$25.00 per image
$
TIFF
@
_____
300 ppi
of an OSI requiring Special Handling or Expedited Service
$50.00 per image
$
TIFF
@
_____
300 ppi
of an OSI requiring Special Handling and Expedited Service
$75.00 per image
$
TIFF
@
Audio or Video Copies
Audio
Video-Reference
Video-Production-quality
For MDAH use only
_____
Hours of production time
$40.00 per hour
$
@
_____
Hours of production time including Expedited Service
$80.00 per hour
$
@
Service charges are in addition to the charges listed above.
Services
_____
Outside Vendor Delivery and Return (quotation required, $40.00 per round trip)
$
_____
$40.00 per hour
$
@
Staff Oversight
_____
Use Fees (quotation and written agreement required)
$
_____
$
Other:
S
$
UBTOTAL
0.00
*P
A
R
*
AYMENT IN
DVANCE IS
EQUIRED
Make checks payable to:
$
Delivery to Patron
(Per quotation OR $3 by U.S. Mail OR $8 by electronic transfer)
MDAH, Archives & Records Services Division
T
D
$
OTAL
UE
0.00
For MDAH use only
Use Permission Completed
OR
MDAH, A&RS Div. Publication Permission Form
Formal A&RS Div. use agreement
Material checked for Restrictions Staff: ________
Date: ____________
AV Agreement No.
D
P
ATE
AID
-OVER-
(Order Form/Invoice, Rev. 10/2015)
Name:
Delivery:
AV Agreement No.
Order No.
Business:
See delivery charges on reverse.
Address:
Regular U.S. Mail
Pick up when ready
City/State:
Express mail service*
Phone Number:
*
Provide your carrier name and account number above.
Email:
Electronic transfer**
**
Provide your email address to the left.
To receive a quotation or place an order, please complete this form and send it to:
Mississippi Department of Archives and History, Attn.: Archives and Records Services Division, P.O. Box 571, Jackson, MS 39205-0571
Or contact MDAH by: Telephone 601-576-6876  Facsimile 601-576-6964  Email refdesk@mdah.ms.gov
Visit us on the Web at www.mdah.ms.gov
 NOTICE 
W
C
C
R
ARNING
ONCERNING
OPYRIGHT
ESTRICTIONS
The copyright law of the United States (Title 17, United States Code, in accordance with the Berne Convention for the Protection of Literary and Artistic Works)
governs the making of photocopies or other reproduction of copyrighted material. Under certain conditions specified in the law, libraries and archives are authorized to
furnish a photocopy or other reproduction, which 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.
This institution reserves the right to refuse to accept a copy order if, in its judgment, fulfillment of the order would involve violation of copyright law.
R
I
EQUESTED
TEMS
Quantity
Accession or Item Number
Description of Material
Location
For MDAH use only
or
or
or
or
Area/Checked
AV Reel
Audio or Video (AV) Item Number
AV Description of Material
AV - No location needed
/
/
/
/
/
/
/
/
/
For MDAH use only
Taken by/Date
Pulled by/Date
Transferred by/Date
Filled by/Date
Returned by/Date
Mailed/Transferred/Picked up
(Order Form/Invoice, Rev. 10/2015)
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