"Permission Form to Reproduce an Image" - Virginia

Permission Form to Reproduce an Image is a legal document that was released by the Virginia Department of Historic Resources - a government authority operating within Virginia.

Form Details:

  • The latest edition currently provided by the Virginia Department of Historic Resources;
  • 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 Virginia Department of Historic Resources.

ADVERTISEMENT
ADVERTISEMENT

Download "Permission Form to Reproduce an Image" - Virginia

Download PDF

Fill PDF online

Rate (4.6 / 5) 34 votes
Virginia Department of Historic Resources
Permission Form to Reproduce an Image
Name:
Address:
City:
State:
Zip:
I/we hereby apply to the Virginia Department of Historic Resources for permission to
reproduce the following item(s):
1.
2.
3.
4.
For Published and Video/Digital Works:
Please check type and each use that applies.
Type:
Non-Profit/University
Commercial
Usage:
Editorial-Books
Video-Broadcasts
Website
Video-DVD
Editorial-Periodicals
Cover Use
Digital/Electronic
For
Editorial-Other
Video-Other
(other than web)
Reproduction in:
Publisher/Producer/:
For Exhibition
Exhibition Title:
Institution:
Display Period::
Virginia Department of Historic Resources
Permission Form to Reproduce an Image
Name:
Address:
City:
State:
Zip:
I/we hereby apply to the Virginia Department of Historic Resources for permission to
reproduce the following item(s):
1.
2.
3.
4.
For Published and Video/Digital Works:
Please check type and each use that applies.
Type:
Non-Profit/University
Commercial
Usage:
Editorial-Books
Video-Broadcasts
Website
Video-DVD
Editorial-Periodicals
Cover Use
Digital/Electronic
For
Editorial-Other
Video-Other
(other than web)
Reproduction in:
Publisher/Producer/:
For Exhibition
Exhibition Title:
Institution:
Display Period::
The Virginia Department of Historic Resources in no way waives its right to
future use of this/these item(s) or the right to grant others permission to use it/
them.
I agree to furnish one complimentary copy of the work to the Virginia Department of Historic
Resources. I assume full responsibility in regard to copyright and other restrictions involved in
the publication of this/these material(s).
Signed:
Date:
DHR Staff Use Only:
Permission to reproduce the above item(s) is:
Approved
Denied
Signed:
(VDHR)
Please mail form to: Randy Jones, 462 Lee Avenue, Harrisonburg VA 22802 or email form to
randy.jones@dhr.virginia.gov
DHR PERMISSION TO PUBLISH FORM
Conditions:
1. To use the photographic copy only once and only for the purpose listed in the letter of agreement’s “State-
ment of Intended Use. ” Use on an end paper or dust jacket or as any other advertisement constitutes a sepa-
rate use and must be applied for in writing. Additionally, any subsequent editions and/or different languages,
etc., constitutes re-use and must be applied for in writing.
2. To credit properly. The following is the basic credit line (unless otherwise specified): “Virginia Department of
Historic Resources”. We ask that you follow these guidelines:
• Published materials: the credit line should be easily accessible.
• Films, filmstrips and video presentations: include the credit within the “Sources for Illustrations” or
“Credits” section of the production.
• Exhibitions: credit should appear in the exhibition area, preferably directly below or adjacent to the orig-
inal copy.
3. To give DHR one complimentary copy of any published work, including CD-ROM products, in which the
photographic copy appears.
4. To indicate in the accompanying caption or label any and all changes or alterations that have been made to
the original copy, including cropping, tinting or detailing.
5. To not permit others to reproduce the photographic copy or any facsimile of it.
6. In authorizing the reproduction of works in its collections, DHR does not surrender its own right to publish
or grant permission to publish to other to do so.
7. Any exceptions or modifications to the above agreement will appear on, and be part of, DHR’s letter of agree-
ment.
Page of 2