River of Words: Services

Workshops | Licensing | Presentations | Traveling Exhibits | Consulting

Request for Use of Image/Poetry

Contact Person: _________________________________________

Organization:____________________________________________

Is the organization a non-profit? Yes_____ No______

Address: __________________________________

City: ____________________________ State: ______ Zip__________________

Telephone:_________________________________

Fax:________________________________________

How will this image/poem be used? If in a publication, please specify size and location (i.e. 1/4 page, 1/2 page, cover, backcover, etc), type and quantity of run. If other please give the most details possible about the dimensions.

Description of the image(s)/poems(s) pending approval (including title, artist, and year entered in contest)

Images/Poems must be cited in the following manner:

Title
Artist, artist’s age
Artist’s home town and state
Prize status (i.e. 2002 Grand Prize Winner, 2000 Finalist)
© 2003 River of Words

Conditions of Request:

Unless otherwise agreed, I understand this is request is for a one-time use.
If slides have been provided to me, I agree to return these within 10 days, unless an extension is granted for their use.
If the images/poems are scanned, each use of a scanned image requires explicit permission.
Please provide three copies of the published or final image for our records.
If the slides are lost or damaged, replacement costs will be borne by the borrower.
Cost of reprint permission for our imagery/poetry is negotiable, based upon usage and distribution.

Signature: Date: _______________________

Approved by: Date:_______________________

River of Words^® · 2547 Eighth Street, 13B · Berkeley, CA 94710 USA
info@riverofwords.org · Phone:510-548-7636 · Fax:510-548-2095