Image Reproduction Request Form | London Public Library

Service Alerts

Prior to completing this form, please read the Licensing Agreement.

Date: *

Date form is being submitted

Name: *

Your name

Street: *

Apt, # Street Name

City: *

City of Residence

Prov/State:

Postal Code / Zip: *

Email:

Telephone: *

Alternate Phone:

Fax:

Image Name 1: *

Name of the first image

Local Identifier 1: *

Local Identifier # for the image

Intended Use 1: *

Personal use

Display / Exhibition ($)

Publication (print, electronic, website) ($)

Presentation (DVD, video, film, PowerPoint, CD-ROM, TV or web broadcast)($)

Image Name 2:

Name of second image (if required)

Local Identifier 2:

Intended Use 2: *

Personal use

Display / Exhibition ($)

Publication (print, electronic, website) ($)

Presentation (DVD, video, film, PowerPoint, CD-ROM, TV or web broadcast)($)

Licensing Agreement: *

I have read, and accept the Licensing Agreement