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State Form 53562
Name of Requester:
Address (number and street):
State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Dist. of Col. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Fed. States Micronesia Guam Marshall Islands North Mariana Is. Puerto Rico Virgin Islands Other (Use Address Lines)
Date of Request (month, day, year):
COMMERCIAL Book, periodical or other publisher Advertising agency, interior decorator, commercial artist Broadcaster, filmmaker, or other media producer Other:
NON-COMMERCIAL Academic Non-profit organization 501c number Newspaper/other media editorial use Other:
Name/Title of Project:
Description of Project:
Date of Release (month, day, year):
Asset medium: Image Video Audio Text / Article
Are you requesting to: Use this asset in a book, periodical, or other physical publication Use this asset in an e-book or other digital publication Create a derivative work based on this asset (i.e. art reproductions) Post the asset online
Item(s) Requested (Please include a brief description & file name, if known ):
How would you prefer to receive the image(s)?
Please read and verify the following statement by marking the box provided:
I have received a copy of the IDNR-Communications Multimedia Policy and agree to comply with the conditions and copyright restrictions described.
I am an authorized representative of the publisher or producer of the project described on this form and wish to be granted one-time-use rights for the listed images.
I agree with the above statements.
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