Header

Sub Navigation

Main Content

Article

Intellectual Property Use Rights Request Form

State Form 53562

Name of Requester:

Company:

Address (number and street):

City:

State:

ZIP code:

Telephone number:

Date of Request (month, day, year):

Email Address:

TYPE OF USER

COMMERCIAL
Book, periodical or other publisher
Advertising agency, interior decorator, commercial artist
Broadcaster, filmmaker, or other media producer
Other:

NON-COMMERCIAL
Academic
Non-profit organization 501c number
Newspaper/other media editorial use
Other:

PROJECT INFORMATION

Name/Title of Project:

Description of Project:

Date of Release (month, day, year):

Publication Medium:

Asset medium:
Image
Video
Audio
Text / Article

Are you requesting to:
Use this asset in a book, periodical, or other physical publication
Use this asset in an e-book or other digital publication
Create a derivative work based on this asset (i.e. art reproductions)
Post the asset online

TRANSFER OF ASSET

Item(s) Requested (Please include a brief description & file name, if known ):

How would you prefer to receive the image(s)?

By Email- If your email has an incoming message size restriction, please indicate:
Send to above email address.
Send to this email address:
On Disk
Mail disk to above address.
Mail disk to this address:
Address:
City:
State:
ZIP code:
Other (i.e. FTP upload) –please include instructions in notes area.

NOTES/ADDITIONAL INFORMATION

Please read and verify the following statement by marking the box provided:

I have received a copy of the IDNR-Communications Multimedia Policy and agree to comply with the conditions and copyright restrictions described.

I am an authorized representative of the publisher or producer of the project described on this form and wish to be granted one-time-use rights for the listed images.

I agree with the above statements.