IMAGE ORDER FORM.
Contract #_________________________(THF use only)
Name: _____________________________________________________________________
Company/Organization: _______________________________________________________
Address: ____________________________________________________________________
City/State/Zip: _______________________________________________________________
Phone: ___________________________ Fax: ______________________________
Email: ________________________________________________________________
INTENDED USE OF MATERIAL:
___ Personal research and will not be copied, reproduced, or publicly displayed.
___ Public display at: __________________________________________________________
___ Reproduction:
Author/Publisher/Director/Producer: _____________________________________________________
Title or description of use: ___________________________________________
Publisher: ____________________________________________________
Projected date of publication: ___________________________________________
Format: _____________ Number of copies or size of market _____________
Statement of responsibility: I certify that the information on this form is correct and I accept the conditions of use. I am authorized to enter into this agreement on behalf of the above named organization.
Signature of Applicant: ______________________________________________ Date: __________________
MATERIAL REQUESTED (Payment in full required before order will be processed)
Image description: Quantity/ Size/ Cost
_________________________________________________________________________________________________
______________________________________________________________________________________________
_______________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
For scan request: dpi: _____; size (in inches) _________. Mac or PC (circle one). ___ Email (if under 3 mb)
Ship via: ___ US Priority Mail. ___ UPS. ___ FedEx (Acct. # _____________________________________ ).
Total amount: _____________. Make your check payable to: Tile Heritage Foundation.
You may also pay by credit card: Visa, Mastercard or Discover.
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Expiration: _____/_____
Signature: ___________________________________________________________
Image requests will only be processed upon receipt of both this form & your payment.
Tile Heritage Foundation, P. O. Box 1850, Healdsburg, CA 95448
Phone: 707 431-8453. Fax: 707 431-8455.
Email: foundation@tileheritage.org