AGSA Image Request Form

AGSA Research and Study Image Request Form
Applicant Details:
Full Name*

First NameLast Name
Name of organisation (if applicable):
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
E-mail*
example@example.com
Details of the Work(s) of Art (specify name of artist and title of work): *
Please note additional fees may apply if new photography is required.
Proposed use of Work/s of Art*

EditorialResearch (includes reproduction within PhD Thesis)StudyPresentation (lectures, seminars and tutorials)Other
If selected other in the above question please specify the intended use:
Enter in relevant project details and scope of image use: *
How will the image be used in the context of research or study
Date image is required: *

MonthDayYear
If new photography is required, it may take up to 12 weeks to have the images ready
Will the research be distributed or made publicly available?

YesNoUnsure
If you selected unsure, please provide additional details
Is the work still within copyright?

YesNo
I hereby declare that I require this photographic material for the purpose specified only under the fair dealing provision (Division 3) of the Australian Copyright Act 1968. I agree not to use the material for any other purpose. Should I wish to reproduce or communicate the material supplied I agree to contact the Gallery to obtain permission and reproduction quality photographic material and if required to contact the copyright holder to obtain copyright permission. I agree to indemnify the Gallery for any copyright infringement that I cause.
Applicant Signature

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AGSA Research and Study Image Request Form