Photographic Reproduction Request

                                                                                                Date of Request:                                             

Name:                                                                                                                                                                                                  

Address:                                                                                                                                                                                             

City:                                                                                                      State:                       Zip Code:                                       

Telephone:                                                                              Fax:                                                                                                   

DESCRIPTION OF OBJECT(S)                                                                             ACCESSION NUMBER

(1)                                                                                                                                                       

(2)                                                                                                                                                       

(3)                                                                                                                                                       

(4)                                                                                                                                                       

(5)                                                                                                                                                       

Purpose and Use of Images:                                                                                                                  

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

Type of Reproduction Requested:

  5x7 black-and-white print      5x7 color print     8x10 black-and-white print      8x10 color print     35mm slide      

  other                                                                                                                                                                                                

 

I have read the Louisiana State Museum’s Conditions Governing Reproductions attached to this form and understand the requirements and restrictions, by which I agree to be bound, in the event permission is granted, and which are expressly incorporated into this Photographic Reproduction Request agreement by reference.  I further agree to promptly pay all applicable fees.

 

Applicant’s Signature:                                                                            Date:                                        

Print Name:                                                                         Title:                                                          

 

 

Please allow a minimum of three weeks processing time.