HISTORIC IMAGE RELEASE FORM

Pioneer Room - Image Release Form

For image donations to the Pioneer Room where the donor retains the original negatives, photographs, or other image-related materials. For more information, contact the Pioneer Room at 760-839-4315 or pioneer.room@escondidolibrary.org.
Owner or authorized agent of the property*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Description of property*
I hereby authorize the Escondido Public Library - Pioneer Room (hereafter cited as “the Pioneer Room”) to make a photographic copy negative(s) or other reproduction such as a digitized copy of photograph(s) identified above as “the property described.” I understand that once my photograph(s) is copied in any format by the Pioneer Room, the photographic copy is in the possession of the Pioneer Room, becomes a public record, and its use is governed by the legal requirements that are applicable to public records. I understand that I waive all title and rights so far as I possess them to the negative(s) described and to
any future prints or copies produced from it/them.

I understand that I retain rights to my original photograph(s).

These materials and any future additions made to the collection shall be accessible to researchers in accordance with the policies and procedures of the Escondido Public Library - Pioneer Room. Duplicate and other non-unique material may be removed from the files or discarded. Researchers may copy material based on fair-use for research purposes. It is intended by the undersigned that the above conveyance and transfer be final, complete and irrevocable upon delivery of the above described property to the Escondido Public Library.
Donor Name*

First NameLast Name
Donor Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Pioneer Room - Image Release Form