Permission to Use and/or Publish Form
Updated 12/12/2002
Approved by the Board of Directors
1/23/2003

Permission to use and/or publish materials owned by the Cumberland County Historical Society may be granted upon request. In most cases literary, or intellectual property rights were not transferred to the Society, therefore the user and/or publishing party assumes full and sole responsibility for any and all issues related to rights, including (but not exclusive to) copyright, privacy, intellectual, or literary rights.

Permission for use and/or publication does not take effect until a signed copy bearing the appropriate staff member’s signature and the signature of the requestor on this form has been received by the Society.

Permission is for one-time use only and is non-exclusive.

Subsequent or multiple editions or publications are subject to additional usage fees.

Patron must send a complimentary copy of any material where reproductions of item or items from the Cumberland County Historical Society were used and/or published to the above address within a sixty-day period.

Attribution must read: “Cumberland County Historical Society, Carlisle, PA.”

Each illustration must be individually credited.

I understand and concur with the above statements. I have read the Cumberland County Historical Society Usage/Publication Policy and fully agree to adhere to all points stated within this document.
 

Name (Please Print)_____________________________________
 

Name (Signature) _______________________________________
 

Company/Agency/Organization (if applicable)_________________________________
 

Address_____________________________________________

 _____________________________________________
 

Phone Number (_____)_______________________
 

Email Address______________________________
 

Website URL (If applicable)_______________________

Title of Publication/Project/Website/Paper, etc.____________________________
 

Number of copies to be published and/or produced_________________________
 

Publisher’s Name (if applicable)________________________________________
 
 

Publisher’s Address (if applicable)______________________________________
 
 

Publishers Phone Number (if applicable) (_____)_______________________
 
 

Date of Publication (if applicable)_____________________________________
 

Images Requested for Use and/or Publication

 Collection #   Description

1)

2)

 3)

 4)

 5)

 6)

  List additional requests on a separate sheet.
 

STAFF APPOVAL:
 

Name (Please print)___________________________
 

Name (Signature)_____________________________

Title_________________________________________

Date________________________________________