Application for Permission to Publish
Please complete, print, and mail or fax this form the RIT Cary Graphic Arts Collection.
Name of Applicant:

Organization or agency:
Address:
City / St /Zip:
Country:
Phone:
Fax:
Email:

Intended Use of Material
Please identify your status by checking one category:
Commercial firms (including publishers)
Non-profit organizations and independent researchers
RIT Alumni
RIT faculty, staff and students

Please identify the intended use of materials by checking one category:
These materials are for personal research.
These materials will be reproduced. (Please attach a description of the project, if available.)

Author, Director, Producer:
Title or description of use:
Projected date of publication:

Format:
Book
Magazine
Film/Video program
Advertisement
CD-ROM/multimedia
School project/paper
Other:

Estimated size of edition:
(# copies/size of market)


Reproduction Materials from the RIT Cary Graphic Arts Collection
Please specify the following information
(attach a separate sheet if necessary):
Call number:
Artist or Collection:
Page Number:
Web page:
Title or Descriptions:

Please specify reproduction type:
35 mm slide
Digital scan or digital photograph, on CD-ROM
 size requirements
Please make a special request if you require a different reproduction format; additional charges may apply.

Please note that materials will be mailed by standard USPS mail, unless specialized courier services are pre-paid by the applicant.
Other Carrier:
(i.e. Fed Ex, UPS, Airborne Exp.)
Please specify type of service:
(i.e. overnight, 2-day, etc.)
Carrier Account
Account #:

MasterCard VISA
Card #:
Exp. Date:
Signature:


Reproduction Fees
Check, Money Order drawn in U.S. dollars made payable to “Cary Library."
MasterCard VISA
Card #:
Exp. Date:
Signature:


By signing this application, I accept personally and on the behalf of any organization I represent the conditions set forth above:
Dated Signed

When signed by an authorized agent of the RIT Cary Graphic Arts Collection this form constitutes permission for reproduction as outlined in this application. The requested materials will be prepared and mailed with invoice.
Dated Signed

Please complete, print, and mail or fax this form to:
Cary Graphic Arts Collection
Rochester Institute of Technology
90 Lomb Memorial Drive
Rochester, NY 14623-5604
Phone: (585) 475-2408
Fax: (585) 475-6900