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Prior to publishing, exhibiting, or otherwise
using any image from the Pennsylvania Hospital Historic Image
Collection, you will be asked to read, complete, sign and
submit the following form for approval by the Pennsylvania
Hospital Archivist.
Permission to Publish and/or Exhibit Materials
From the Pennsylvania Hospital Historic Collections
800 Spruce Street, Philadelphia, Pennsylvania 19107
Name: _______________________________________________________________________
Institution: ____________________________________________________________________
Address: _____________________________________________________________________
Phone: ________________________________ Email:
_________________________________
________________________________________________________________________________
I, the undersigned, as a representative of __________________________________,
wish to
publish and/ or exhibit the following materials from the Pennsylvania
Hospital Historic Collections:
(Please be as specific as possible)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
I/ we will be using the aforementioned materials
in the following publication/ exhibit:
(please provide title of work and publication
date, if known. If using items in an exhibit, please include
dates of use.)
_____________________________________________________________________________
_____________________________________________________________________________
Please carefully read the following policy
and regulations concerning use:
1) In providing permission to
publish material obtained from the Pennsylvania Hospital Historic
Collections, the Hospital does not assume any responsibility
for infringement of copyright or of publication rights for
materials that might be held by others. The publisher/ undersigned
assumes all responsibility for any claims under the Copyright
Law or the laws of libel that could be made as the result
of the publication.
2) The responsibility for obtaining
any additional permission required for publication of archival
materials remains with the publisher of the material.
3) The publisher/ undersigned
understands that he/ she will be granted one-time, non-exclusive
rights to use Hospital materials. The Pennsylvania Hospital
retains the right to publish, and provide to other patrons,
said materials. Any subsequent use of said materials by the
publisher/ undersigned will require additional permission,
and is subject to additional publication/ use fees. Images
may not be transferred to another individual or organization,
be deposited at another institution, or be reduplicated without
prior permission of the Pennsylvania Hospital.
4) The publisher/ undersigned
agrees to cite the source of archival material in all published
works and exhibits. A dissertation is considered a published
work. All materials should be credited as follows: "Courtesy
Pennsylvania Hospital Historic Collections, Philadelphia."
I have read the policy as stated above
and agree to comply with its regulations.
Signature: _________________________________________
Date: ______________________
Approved By: _______________________________________
Date: ______________________
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