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Request Form For The Authorization Of Use Of Images

request form for the authorization of use of images from museo galileo’s photographic archives name ___________________________________

Request Form for the Authorization of Use of Images
from Museo Galileo’s Photographic Archives
Name
__________________________________________________________________________
Institution or Group
_______________________________________________________________
Address_________________________________________________________________________
Vat Number (only for members of European Community)________________________________________
Tel.: _________________ Fax: _________________ e-mail:
____________________________
I, the undersigned, have read and accept the conditions stated in the
Regulations and hereby request permission to reproduce and obtain the
authorization of use of the following images from Museo Galileo’s
Photographic Archives:
Title__________________________________________________________________________
Photographic Inventory
___________________________________________________________
Other information
_______________________________________________________________
T ype of Reproduction : High resolution file Low
resolution file

Color Black/White
I accept the conditions stated in the Regulations and hereby request
authorization of use of the following images from Museo Galileo’s
Photographic Archives:
Title__________________________________________________________________________
Photographic Inventory
___________________________________________________________
Other information
_______________________________________________________________
For the following Publication
Title
_____________________________________________________________________________
Nature of publication and press run
__________________________________________________
For Other Use
________________________________________________________________________
Date ______________________ Signature _______________________________

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