Permission to Publish Form - Georgia Tech Library

APPLICATION FOR PERMISSION TO PUBLISH
I. Applicant Information
Name & Title:
Company:
Email:
Address:
Phone:
Fax:
II. Publication Information
Format: Book Periodical Film/Video/TV Online
Exhibit/Display CD/Multimedia Thesis/Dissertation Reprint/Reuse
Title:
Other:
Author/Producer:
Publisher/Production Company:
Contact Person:
Email:
Address:
Phone:
Fax:
Expected Date of Publication/Broadcast/Exhibit/Etc.:
URL (if to be used online):
This use is: Commercial Non-profit Educational
III. Material(s) To Be Used (attach additional pages if necessary)
Citation
Title/Description
Georgia Institute of Technology Archives and Records Management
Application for Permission to Publish, May 2009 page 1 of 2

IV.
Conditions for Use
1. Permission for reproduction is granted only for
the expressed purpose described in this
application. Permission is for one-time use
only, for the life of the project. Any
subsequent use constitutes reuse and a new
Application for Permission to Publish must be
submitted.
2. Permission is granted only for the applicant's
final product and is non-transferable, except
when noted on Application for Permission to
Publish.
3. Materials to be published must be obtained
directly from the Georgia Institute of
Technology Library and Information Center,
Archives and Records Management
Department.
4. The Georgia Institute of Technology Library
and Information Center, Archives and
Records Management Department reserves
the right to refuse reproduction of images if it
believes any of the following:
• Reproduction would be in violation of
copyright or other laws.
• Reproduction would violate the policies
and/or procedures of the Institute.
• An individual depicted in a reproduction has
privacy rights. The Georgia Institute of
Technology reserves the right to require
releases from individuals whose privacy
may be violated by reproduction of this
image.
5. Images must be reproduced without
alteration. Requests to alter images,
including cropping, bleeding, overlapping,
detail only, digital enhancement, etc. must be
approved and so indicated on the
Application for Permission to Publish.
6. All images used in publication/display must
use the credit line "Permission of the
Georgia Institute of Technology Library and
Information Center, Archives and Records
Management Department."
7. One complimentary copy of each publication
in which an image is used is requested for
retention in the archives.
8. It is the responsibility of the applicant to
determine copyright and to obtain permission
from the current copyright holder. The
Georgia Institute of Technology Library and
Information Center, Archives and Records
Management Department assumes no
responsibility for any royalties or fees
claimed by the artist or creator, or on the
artist's or creator's behalf. The applicant
agrees to assume full responsibility for the
use of materials obtained from the Georgia
Institute of Technology Library and
Information Center, Archives and Records
Management Department and to hold
harmless the Institute and its agents against
any and all damages and claims arising or
resulting from the use of the images.
V. Agreement
Permission to publish is granted only upon completion of application, approval, and payment of
all fees. Applicant agrees to abide by the terms and conditions listed above.
Signature of Applicant:
Date:
Permission is for one-time use, non-exclusive, world-wide rights in all languages in the medium
and format stated in this application.
For Georgia Institute of Technology Archives and Records Management Staff Use Only:
Permission to use materials listed in this application is:
Granted Granted with exceptions (see below) Denied (see below)
Georgia Institute of Technology Archives and Records Management Employee/Title
Date
Fees Paid: $
Explanation/Notes:
Date Paid:
Georgia Institute of Technology Archives and Records Management
Application for Permission to Publish, May 2009 page 2 of 2