Nov 2016
Contact information:
City Province Postal Code
Phone/Fax E-mail
Quantity Image number Size
Reproduction(s) $_____________
Mailing $_____________
Subtotal $_____________
PST 7% $_____________
GST 5% $_____________
Balance Due $_____________
Intended use of reproduction(s)
Please note that reproductions are provided for personal research and enjoyment purposes only. Any other
purpose requires
permission and a fee for use may be charged in addition to the reproduction fee.
Please indicate your intended use:
Personal research and enjoyment
All other uses - please complete the Application for Permission and Licensing Agreement
Signature Date
Archives use (licence number / notes / special instructions): Order number
Archives Image Reproduction Order Form
City of Victoria Archives 1 Centennial Square, Victoria, BC V8W 1P6
T: 250-361-0375
F: 250-361-0367
Please print and sign this document