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

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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

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