DIXON PENTECOSTAL RESEARCH CENTER PERMISSIONS APPLICATION
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Please print this form to submit orders by fax or mail:
The Dixon Pentecostal Research Center 260 11th Street NE Cleveland, TN 37311 Phone: (423) 614-8576 Fax: (423) 614-8555 Email: research@cogheritage.org |
Name__________________________________________ |
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Organization ____________________________________ |
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Address _______________________________________ |
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City __________________________ State ____________ |
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Country ______________________ Zip Code ________ |
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Phone__________________________________________ |
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Fax ___________________________________________ |
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Email __________________________________________ |
IMAGE(S) REQUESTED
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Description, Name, or Subject of Photograph(s) Requested |
Use Fee |
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*Please Consult the Use Fee Schedule Total Due |
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FORMAT NEEDED
□ Reproduction or digital file previously obtained, permission only required.
□ 8”x10” Print □ Low-res JPEG □ High-res TIFF file
□ Other size print (please call for size availability and prices)
SERVICE LEVEL
□ Regular □ Rush (additional $30.00 per image) □ Additional surcharges $________________
USE TO BE MADE OF IMAGES
□ Personal/Research □ Book □ Magazine/Newspaper □ Scholarly Journal □ Web Site
□ Exhibition □ Promotion □ Commercial TV □ Public Television □ Home Video/DVD
□ Other:___________________________________________________________________________
Title of Project: __________________________________________________________________________
Publisher/Production Company: _________________________________________________________
Images to be used in: □ B/W □ Color Placement: □ Interior □ Jacket/Cover
Territory: □ North America □ Worldwide Languages: □ Single □ More than one
Editions: □ First Use □ Reuse Release date: ___________________
Duration (Exhibition/ Web Site only):_______________________ Print Run: ______________________
PAYMENT
Please Send Check or Money Order
DELIVERY
□ Call for pickup □ FTP or HTTP download □ U.S. mail □ Air mail (Additional $10.00 fee)
□ Federal Express □ Airborne Express
Client’s Fed Ex or Airborne Exp. account no. required for delivery: ___________________________
Signature _________________________________________________ Date ______________________________________