Title of Publication: ___________________________________________
Name of Publisher, director, editor, or author: _______________________
__________________________________________________________
Address and telephone number: __________________________________
Theme of publication or production: _______________________________
Estimated date of publication or release: ____________________________
Estimated number of photographs or other items to be used in
publication or production:
Attach list of photographs or other items requested or use
back of this page.
Type of rights desired: _________________________________________
Name of person/organization requesting publication rights
(if different from above):
___________________________________________________________
Address and telephone number: ___________________________________
Tax exempt identification number (if applicable): _______________________
I, __________________________________________________________, agree that the reproduction(s) purchased from the University of Alaska for the above project will be used for this one publication or production only, and that further usage will be renegotiated with the University of Alaska Anchorage, Archives and Manuscripts Department. I will give full credit to the University of Alaska Anchorage, Archives and Special Collections Department and the specific collection(s) used.
Signature: ________________________
Date: ___________
Payment Amount (if applicable): _________
Date: ___________
[ The Form "AUTHORIZATION TO PUBLISH MATERIALS FROM THE COLLECTIONS IN THE UAA ARCHIVES AND SPECIAL COLLECTIONS DEPARTMENT" is available in the Archives and Special Collections Department.]