The Arizona Historical Society (AHS) collects and preserves rare and unique material concerning Arizonas history.
To maintain strict intellectual control of the material, permission and attendant fees
are required for the publication, broadcast, or exhibition of AHS materials.
Permission to Publish
Permission to Publish Request
LAA20-008 06/20
Name _____________________________________________________________________________ Date _________________
Company/Institution/Organization (if applicable) ____________________________________________________________
Commercial Self-publish Government Agency Nonprot
Address _________________________________________________________________________________________________
City/State/ZIP Code _______________________________________________________________________________________
Phone ___________________________________________________ Email _________________________________________
INTENDED USE OF MATERIAL
Book
Periodical
Advertisement
School Project or Paper
Dissertation
Film or Video program Social Media Web site
URL: _________________________________________
Other, please specify: _______________________________________________________________________________________________________
Author/Producer: ______________________________________________________________________________________________
Title and Publisher: _____________________________________________________________________________________________
Projected date of use: _________________________________
ITEM NUMBER TITLE/DESCRIPTION UNIT PRICE FEE TOTAL
Subtotal
Delivery
TOTAL
azhs.org | TEMPE (480) 387-5355 | TUCSON (520) 617-1157 | ahsreference@azhs.gov
METHOD OF PAYMENT
Cash Check /Check# Corporate Acct. (send invoice)
Credit Card, please call with credit card information. Please do not email this information.
POLICIES AND CONDITIONS FOR PUBLICATION:
CREDIT FOR MATERIALS SHOULD READ: Arizona Historical Society, Collection Name, Collection Number,
or other unique identier.
Permission to publish will be granted only upon proper completion of this form, including signature from an
AHS representative and payment of requisite fees.
Permission is granted only for the express purpose described in this application and is non-
transferable. Additional uses must be approved before use, including but not limited to: new editions,
multi-language editions, trade, promotional, packaging or advertising use.
Each image must be used unaltered and in its entirety, unless approved in advance by AHS. Resizing the
image is permissible.
Materials obtained from the AHS may not be copied, scanned, exhibited, resold, nor deposited in any library
or collection.
This permission is non-exclusive. AHS reserves the right to reproduce the image and allow others to publish,
broadcast or exhibit the image.
OWNER OF ORIGINAL: If the AHS material is itself a reproduction, the written permission of the owner of
the original is required.
The applicant agrees to send the AHS one complimentary copy of the work containing the reproduction.
AHS must be provided with a website address for image(s) posted on the Internet. AHS reserves the right to
remove its images from any website. Proper credits must be placed adjacent to the image, and must include
the following link to the Arizona Historical Society website at azhs.org.
CULTURAL PROTECTION: AHS extends the right of privacy to include ceremonial objects and rites of
Native Americans. In all instances, the applicant agrees to defend, indemnify and hold the Arizona
Historical Society, and their employees and agents, harmless against any and all claims arising or resulting
from the use of the images.
WARNING CONCERNING COPYRIGHT RESTRICTIONS
The copyright law of the United States (Title 17, U.S. Code) governs the making of photocopies or other
reproductions of copyrighted material. Under certain conditions specied in the law, libraries and archives
are authorized to furnish a photocopy or other reproduction. One of these specied conditions is that the
photocopy or reproduction is not to be “used for any purpose other than private study, scholarship, or
research.” If a user makes a request for, or later uses a photocopy or reproduction for purposes in excess of
“fair use” that user may be liable for copyright infringement. This institution reserves the right to refuse a
copying order if, in its judgment, fulllment of the order would involve violation of copyright law.
It is the responsibility of the researcher to obtain copyright permission, if copyright resides outside AHS.
The publishing party assumes all responsibility for any infringement of the United States copyright law. By
signing this form, the user agrees to indemnify and hold harmless the Arizona Historical Society, their ofcers,
employees and agents from and against all claims, demands, costs, and expenses incurred by copyright
infringement or any other legal or regulatory cause of action arising from the use of AHS materials.
I have read the Policies and Conditions for Publication listed on this form. I certify that the information on this form is
correct and by signing below, I accept the Policies and Conditions for Publication.
Signature _________________________________________________________________________ Date _________________
LAA20-008 06/20
azhs.org | TEMPE (480) 387-5355 | TUCSON (520) 617-1157 | ahsreference@azhs.gov
AHS acknowledges payment in accordance with the conditions specied herein. Permission is hereby granted to the
above for the use described herein.
Approved by AHS Representative:_______________________________________________ Date________________________
STAFF USE ONLY
Receipt# Date Completed Staff Initials
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