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Photo(s) Requested:
In the space provided below, please describe fully the intended use of the referenced image(s)
such as publication, video, exhibition, or personal research. If for publication, list the
author, title, publisher, and date. If for exhibition, list the exhibit's title, the
institution, and duration of exhibit.
Description of Use:
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The Applicant Agrees:
1. To use the image(s) only for the purpose or project stated above.
Later and different use constitutes reuse and is prohibited. Subsequent requests for permission
must be made in writing. A reuse fee may apply.
2. To give proper credit for the image(s). Unless otherwise stated on the photographic
copy, the credit line should read: Scottsville Museum, Scottsville, VA. When the name
of the collection and/or photographer is supplied, this should also be included in the credit.
The placement of credit should be as follows:
a. Printed material - Preferably the credit line should appear on the same page as the
printed copy of the image and immediately adjacent to it. The credit may appear elsewhere in
the publication if done in such a way that readers can quickly match individual images with their
respective credit.
b. Films, filmstrips, video, or electronic media - The credit line should appear on the
film, filmstrip, video, or electronic media where other sources are listed. If manuals
accompany films or filmstrips, the credit should appear where the subject of the illustration is
discussed in the text.
c. Public exhibitions - The credit should appear within the exhibit area.
3. To defend and indemnify and save and hold harmless Scottsville Museum, its digital archives,
its officers, employees, and agents from and against all suits, claims, actions, and expenses arising
out of the release of images to the undersigned applicant and their use in any manner, including
inspection, publication, reproduction, duplication, or printing by anyone for any purpose whatsoever.
4. To defend and indemnify and save and hold harmless Scottsville Museum, its digital archives,
its officers, employees, and agents from and against all suits, claims, actions, and expenses arising
out of the release of images to the undersigned applicant and their use in any manner, including
inspection, publication, reproduction, duplication, or printing by anyone for any purpose whatsoever.
5. To supply Scottsville Museum with one complimentary copy of any published work in which one
or more images appear.
6. Not to permit others to reproduce the image(s), to destroy any digitized copies of images
following their use.
7. Not to place the image(s) in another institution, repository, or collection-public or private.
8. Not to place images on the Internet (video excepted).
9. To return to Scottsville Museum the supplied copies of any images if they are designated by
Scottsville Museum for return.
10. That Scottsville Museum in no way surrenders its own right to publish or otherwise use the
image, or to grant permission for others to do so. That Scottsville Museum reserves the right
to make exceptions or additions to the conditions stated herein.
THE APPLICANT HEREBY AGREES WITH AND ACCEPTS THE ABOVE-STATED CONDITIONS:
Applicant's Signature:
Applicant's Name (Printed):
Address:
Telephone Number:
Date:
Authorization for Use
(To be completed by Scottsville Museum)
To the extent that it has legal authority to do so, Scottsville Museum hereby gives its consent
for the release of the image(s) referenced to the applicant under the conditions and for the purpose
described herein. This consent does not imply that Scottsville Museum controls the copyright
to the image(s) or that the applicant should not secure other authorizations prior to use.
Permission to reproduce the above item(s) is approved denied
For Scottsville Museum:
Date:
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