Rochester Museum & Science Center
657 East Avenue
Rochester, NY 14607
Tel: 585-271-4320
Fax: 585-271-0492
http://www.rmsc.org/

IMAGE REQUEST FORM

Name: 
Date:  
Institution: 
Address: 
Phone: 
Fax: 
Email:   

Project/Publication Title: 

Request Type (delete those which do not apply): Viewing, Reference, Publication

Purpose (delete those which do not apply):  Research/Non-commercial, Commercial, Personal, Educational

Request for  (delete those which do not apply): RMSC staff to provide images, Permission to take own images, Permission for use of image only (image(s) already in requestor's possession)

Objects or Images requested: 

Details of Proposed Use (include description of sequences in which each image will be used if project is film/video): 

Date image needed or preferred date of visit: 

Projected Audience Number (print run or approx. viewing audience): 

Projected Date of Publication/Production: 

Image Format:  _____dpi  _____ x _____ [inches  /cm / pixels]:
Digital or Printed:

Delivery Format [Compact Disk / Email]: 
Black and white or color:

Note: This form does not grant permission to use RMSC images, but is rather a formal request to reproduce images from the collections of RMSC. Please submit this form to an RMSC representative for approval. After approval has been granted, a Terms of Use Agreement will be drafted to outline the specific contractual agreements of the image use.    

I hereby state my formal intent to use an image from the RMSC collections in the manner outlined above:

Signature: 
Date: 

Image Request Form - rev. 2008-03-25