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Request Permission to Publish or Reproduce Montana Room Materials

2. Name or Organization*
   Please provide your full name if applying as an individual. Provide your organization's name if you are applying as a representative.
4. Address
6. City
7. State
8. Zip Code
10. Phone Number*
11. Email Address:*
13. Intended Use:*

    Please check all uses intended for this material.

    1. Book
    2. Magazine/Journal Article
    3. Research: Report, Dissertation, etc.
    4. Print Media

    1. Broadcast Media
    2. Film/Video Production
    3. Presentation
    4. Website

    1. Social Media
    2. Display or Interior Decoration
    3. Other
15. If Other, please explain
16. Estimated Publication or Production Date:
    Estimated Publication or Production Date:
18. Title & Description of Material Requested*
20. Image link from Montana Memory Project*
    Many images have similar titles. Please include a link to ensure that the exact item is matched with your request. Example: Example: https://mtmemory.org/digital/collection/p103401pblhc/id/420/rec/13
22. Conditions*

    I have read and agree to the stated conditions on my behalf and on the behalf of any organization I represent.

    1. Yes
    2. No
24. Name of Person Placing Request*
25. Date*
    Date
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit Submit and Print

* indicates a required field