This Form is required to be completed by individuals requesting use of images from the Museum’s Documentary Multimedia Collection and other Museum images for publication, research, commercial or personal use.

Request for Access and Use of Documentary Multimedia Collection and Other Museum Images or Recordings Form

Part A: Request Information

Name: ______________________________________ Today’s Date: ________

Address: ________________________________________________________

Phone Number: _______________________________ Email:  _____________

Institutional Association: ____________________________________________

Description of images (include Documentary Multimedia Collection accession number):

__________________________________________________________________

__________________________________________________________________

Please describe reason for request and how images are intended to be used.  If images are for publication, presentation or special project, include the name of publication, publisher, expected publication or presentation date. (Attach pages with additional description or documentation to this form.)

__________________________________________________________________

__________________________________________________________________

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Preferred format if images are to be duplicated: __________________________

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Schedule for request including dates when viewer is available to review images if visiting the Museum, date of presentation or publication deadlines:  _________________________

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Part B:  Copyright

If images are to be distributed to the user for any purpose, check one of the three boxes below and follow directions.  Do not complete this section if user is only examining images on Museum grounds.  Complete separate forms if multiple images are being requested that have different copyright status:

______1.Copyright owned by Spurlock Museum and University of Illinois.  If this box is checked, complete the conditions for use below and sign.  If approved as indicated by Spurlock Museum staff signature below, the Museum agrees to provide a copy of the image(s) for use as specified in this form.

______2.Copyright owned by the following individual or organization:

______________________________________________.  If this box is checked, the user must complete one of the two actions below and check the corresponding box.  The Museum will not release any copies unless one of the following is true.

_____User has provided the Museum with documentation showing that permission to have copies has been granted by the owner  (please attach copy to this form); or

_____ Owner has previously granted the Spurlock Museum permission to use images in a manner consistent with the use described above.

______3. Copyright owner cannot be identified or it is unclear whether the material is protected by copyright.  If this box is checked, the user must agree to and initial each of the following statements.  The Museum will release copies for purposes of private use and research only.  It is the user’s responsibility to determine the copyright status of the material and obtain any necessary permission before using the material for any other purpose.

_____ I understand I am solely responsible for securing copyright and other permission that might be required for use.

_____ I agree that the copies are strictly for the purposes identified as “fair uses” by §107 of the Copyright Act: “such as criticism, comment, news reporting, teaching (including multiple copies for classroom use), scholarship, or research.” In determining whether a use in any particular case is a fair use, the factors to be considered include

• the purpose and character of the use, including whether such use is of a commercial nature or is for nonprofit educational purposes;
• the nature of the copyrighted work;
• the amount and substantiality of the portion used in relation to the copyrighted work as a whole; and
• the effect of the use upon the potential market for, or value of, the copyrighted work.

Note that all factors are considered together, not in exclusion.

_____  I agree that before publishing, performing, or broadcasting except according to the conditions of Fair Use, I am responsible for securing permission from the rights holder.

Part C: Conditions for Use

Please sign initials in each box below.  Enter ‘N/A’ if not applicable.

_____            I agree not to handle images unless I have received approved training and have been given express permission by supervising Museum staff.

_____            I understand publication permission is for one time use only and agree to obtain further permission should I wish to publish the image at any time in the future.

_____            I agree to publish the following credit line: ‘Courtesy of The Spurlock Museum, University of Illinois at Urbana-Champaign.’

_____            I will provide the Spurlock Museum with one copy, free of charge, of the publication listed above.

Fees

_____ I agree to reimburse the Museum for expenses incurred in responding to the above request for cost of materials, duplication fees, printing costs, or compensation of staff time and resources in the following amount:  ________.

Signature: _____________________________________            Date: ____________

Request Approved by: ____________________________            Date: _____________

For Office Use Only

Publication received:  Date _____  Initials _____  Library/Publication Number  ________

Other Comments _____________________________________________________________