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  
Email Address  
Phone (hm)   (wk)   (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

 

April 2004

 

OFFICIAL USE ONLY

Order No
Reproduction: Approved/Declined
Form of acknowledgement

 

 

 

Copy for retention: Yes/No

 

Fees: Payable/Exempt

 

 

 

 

Per Unit
Volume Rate
To Pay

 

 

Cash/Account

Receipt No

 

Account No

 

Authority form sent

 

Authorised by