| Application
for Reproduction Rights |
Please fax or post the completed form to: Photograph Librarian,
Special Collections, Auckland City Libraries, PO Box 4138, Auckland 1036, New Zealand, Fax
307-7741 |
| Name
(Mr, Mrs, Ms) |
|
| Organisation
or business name |
|
| Address
|
|
| Phone
(Home) |
|
(Business) |
|
(Fax) |
|
Application is made to reproduce the following
items |
Negative, Page
Item or
Issue No. |
Brief description/Caption/Date etc. |
|
|
| The total number of items to be
reproduced is/are |
|
Nature of, and intended use – please give
full details
(eg. medium, publication type, advertising, campaign length, film, video, etc.)
Please attach any additional information –
supplementary information may be required by the Library.
| Title |
|
Retail price per unit/set |
|
| Author |
|
Distributor |
|
| Publisher |
|
Number of copies |
|
| Publication date |
|
Distribution area |
|
| I have read and agree to
abide by the Library's Conditions for Reproduction |
|
Name (Block Letters) |
Signed |
Date |
May 2001 |
OFFICIAL USE ONLY
| Order No |
| Reproduction:
Approved/Declined |
| Form of
acknowledgement
|
| Copy
for retention: Yes/No |
| Fees:
Payable/Exempt
|
| Per
Unit |
| Volume
Rate |
|
| Cash/Account Receipt No
|
| Account
No |
| Authority
form sent |
| Authorised
by |
|