Image Order Form
Post or scan the completed form to:
Photograph Librarian, Sir George Grey Special Collections, Auckland Libraries
PO Box 4138, Auckland 1140, New Zealand.
Or email form to: library_photos@aucklandcouncil.govt.nz
OFFICIAL USE ONLY
NAME (Mr, Mrs, Ms, Miss)
Order No:
To Photographer:
Work Completed:
Contacted:
Staff:
ORGANISATION OR BUSINESS NAME
ADDRESS
EMAIL ADDRESS
PHONE (HM) (BUSINESS) (FAX)
Photographic or Digital Prints
Negative number
Brief Description
Gloss or
matte
B&W,
Sepia or
colour
Print
size
Photo,
Digital
or
Laser
No. of
copies
CHARGES
INCLUDING GST
Negative
Number
Brief Description
JPEG
or TIFF
Email or CD
TOTAL
PLEASE INDICATE YOUR INTENTIONS BY TICKING ONE OF THE FOLLOWING:
These items are for personal use only and are not for further reproduction
These items are required for reproduction. Complete
Application for Reproduction Rights Form
SIGNED: DATE:
August 2018
Page 1
NAME (Mr, Mrs, Ms, Miss)
ORGANISATION OR BUSINESS NAME
ADDRESS
EMAIL ADDRESS
PHONE (HM)
(BUSINESS)
(FAX)
Negative, Page
Item or Issue No.
Brief Description / Caption / Date etc
Application for Reproduction Rights
Post or scan the completed form to:
Photograph Librarian, Sir George Grey Special Collections Auckland Libraries
PO Box 4138, Auckland 1140, New Zealand.
Or email form to: library_photos@aucklandcouncil.govt.nz
OFFICIAL USE ONLY
Order
No:
PHONE: (HM) (BUSINESS) (FAX) Reproduction
:
Approved /
Declined
Form of
Acknowledgement:
Copy for Retention:
Yes / No
Fees:
Payable /
Exempt
THE TOTAL NUMBER OF ITEMS TO BE REPRODUCED IS/ARE
Per Unit:
NATURE OF AND INTENDED USE PLEASE GIVE FULL DETAILS
To
Pay
:
Please attach any additional information supplementary information may be required by the Library.
TITLE
RETAIL PRICE PER UNIT/SET
AUTHOR
DISTRIBUTOR
Authority Form Sent:
PUBLISHER NUMBER OF COPIES
PUBLICATION DATE DISTRIBUTION AREA
I HAVE READ AND AGREE TO ABIDE BY THE LIBRARY’S CONDITIONS FOR REPRODUCTION
Authorised By:
NAME (Block Letters) SIGNED DATE
August 2018
Page 2
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