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Please use the form below to request permission to reproduce materials owned the Chatham Historical Society.


Please review the Society's Collection Use and Photocopy Policy and Fees.

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APPLICATION FOR PERMISSION TO REPRODUCE ANY MATERIALS
OWNED BY THE CHATHAM HISTORICAL SOCIETY

Please complete all applicable sections of this form and return to the Chatham Historical Society, P.O. Box 709, Chatham, MA 02633. A countersigned copy of this form will be returned to you when permission has been granted.

Applicant:
Address:
Telephone:                                         Fax:
E-mail Address:
Applies for permission to reproduce:

For the following publication OR Other Use (describe)

Title:
Author or Editor:
Periodical name (if applicable):
Publisher and address:
Expected date of publication:

Circle all that apply regarding publication or exhibition:

Non-profit      Commercial      University Press      Book     Textbook     Periodical      Exhibition catalog      Dissertation
Other (describe):

Circle all that apply regarding the reproduction:
Color     Black and White     Cover    Double-page     Full Page (8x10 or larger)     Half page    Quarter Page

Rights: One time, English use. Credit line must read: Courtesy, The Chatham (MA) Historical Society

If granted permission for the uses above, I agree to abide by the provisions as stated in the Society’s

Collection Use and Photocopy Policy and Fees.,

Signature of applicant Date
 
Signature for CHS Date
(Title)

Form approved by the executive board of The Chatham Historical Society at its meeting on January 19, 2008.