Free Indiana Department of Natural Resources - Indiana

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Indiana Department of Natural Resources Division of Communications/Outdoor Indiana Magazine 402 W. Washington Street, Room W255B Indianapolis, IN 46204-2748 317-234-5590 (Voice) 317-232-8036 (FAX)

PERMISSIONS & IMAGE RELEASE REQUEST
State Form 53562 (4-08)

Requester Name: ________________________________ Company: _________________________________ Address:__________________________________________________________________________________ City/State/ZIP:_____________________________________________________________________________ Phone:_______________________________________ Date of Request:_______________________________ Email:____________________________________________________________________________________ TYPE OF USER COMMERCIAL Book, periodical or other publisher Advertising agency, interior decorator, commercial artist News Broadcaster, filmmaker, or other media producer Other: ________________________ NON-COMMERCIAL Academic Non-profit org: 501c3#:_____________ Grant program (specify):__________________ Other: ________________________

PROJECT INFORMATION
(Hover over fields for examples.)

Project name/title: __________________________________________________________________________ Project Description: _________________________________________________________________________ Date of Release: _________________ Publication Medium: _________________________________________ Description of material requested: ______________________________________________________________ IMAGE ACQUISITION How would you prefer to receive the image(s)? By Email Send to above email address. Send to this email address: __________________________________________________ On Disk Mail disk to above address. Mail disk to this address: ___________________________________________________ City /State/zip: __________________________________________________ Shipping Information Shipping Company: DHL FedEx UPS USPS Shipping Code: ________________________________________ NOTES/ADDITIONAL INFORMATION:

IMAGE SIZE:
(High resolutions might not be available for all photos. Thus, higher minimums may limit availability.)

Minimum Resolution: 72 dpi 150 dpi 300 dpi

Minimum Size: 5x7 inches 8x10 inches Other: ________

(Optional) Desired Pixel Size: _________ x _________

Acceptable Formats: .tif .jpg Other: _________

Image(s) Requested (Descriptions/Location in Outdoor Indiana/etc.): File Name(s) (if known): __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Note: When requesting more than10 images, please use an additional form or follow directions from archivist.

Please read and verify the following statement by marking the box provided:
I have received a copy of the IDNR-Communications Photo 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. Signature (if mailing or faxing): X__________________________________

IDNR Contact: Megan M. Coy, Digital Archivist, (317) 234-5590, [email protected]

Internal Use Only: *IDNR hereby grants one-time rights to reproduce the item(s) requested for the project described. IDNR authorization: Date: Credit Line:
Invoice #: Notes: