Using an image from Special Collections in a publication or electronic product

 

Please complete this form if you wish to reproduce (in digital or photographic form) any item or any portion of any item held in the Department of Special Collections. Note that you are seeking the permission of the General Library System in its capacity as owner of the physical object. You and/or your publisher are responsible for satisfying the claims of any heirs or assigns concerning intellectual property rights inhering in the item in question.

 

Name

 

Address

 

 

Phone

voice (      )                                                        fax (      )

E-mail

 

 

Source of image (book, manuscript)

 

Author

 

Title

 

Publisher

 

Publication date

 

Page number

 

Details about image

 

Call number

 

 

Requesting permission to use this image in a publication or electronic product

·         Please complete and sign the front (or first page) of this form. The completed permission decision will be returned to you.

·         A credit line (see wording on page two of this form) must be included in the publication or other product.

·         Reproducing an image in an electronic product (Web site, CD-ROM, etc.) requires permission, just as for print publication.

·         See the back of this form for the permission decision.

·         Note to graduate students: A dissertation or master’s thesis is, in fact, a publication, and hence explicit permission is required to use an image from our holdings in a dissertation or thesis. 

 

Author/editor

 

Title of book, article, dissertation, or other product

 

If an article, title of journal or book in which it will appear

 

Approximate length of book or article

 

No. of copies of book

 

Publisher or Web site owner

 

Est. publication date

 

 

Other use

Personal use

(please explain)

 

 

 

 

_____________________________________________________________     __________________________

Signature     REQUIRED                                                                                      Date

 

_____________________________________________________________     __________________________

Received by                                                                                                             Date


Permission decision

 

 

Concerning the request made by ______________________

 (copy attached)

 

Insofar and only insofar as our rights extend, the General Library System, University of Wisconsin–Madison, licenses you to reproduce the image listed below in the publication you have described:

 

 

 

 

 

 

 

 

 

 

 

 

r If this box is checked, permission is contingent upon receipt of a use fee ______  (invoiced separately).

 

This permission is granted for this one use only, and does not imply or convey permission for publication in any other form, print, electronic, or otherwise. That is, this material cannot be otherwise reproduced, republished, uploaded, posted, transmitted, translated, or distributed without our explicit permission.

 

Please use the following credit line:

 

Reproduced by courtesy of the Department of Special Collections, General Library System, University of Wisconsin-Madison.

 

Please supply the Department (address below) with a copy of the publication. This applies as well to electronic products.

 

 

 

 

 

 

 

_____________________________________________________________     __________________________

                                                                                                                              Date

Robin Rider

Curator of Special Collections