Federal Tax ID# 45-6013195

Payment must be made at time of order unless other arrangements are made in advance. Photographs are provided for reference use only. If you are seeking permission for commercial use, exhibit, or publication check here G and complete permission request form

Ordered By	Date Ordered		Telephone No.
Street Address	City	State	Zip Code

G Print processing G Scan/digital image G Photograph of museum artifact CD Format G PC G MAC

QUANTITY	PRINT SIZE / PPI			COLLECTION #		ITEM NO.	DESCRIPTION			COST
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ND Sales Tax										$
Shipping and handling										$
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I understand that the State Historical Society of North Dakota is providing the requested copy or copies for my own personal enjoyment or private study, scholarship, or research (as defined by the “Fair Use” clause of the copyright law of the United States, Title 17 United States Code). I understand that any use beyond the ones identified must be applied for through the submission of a Request for One Time Use of Photographic Image form. ____________________________________________________ Patron’s signature
Instructions G Ship G Pick up
FOR DEPARTMENT USE ONLY
Date Completed			By		Time			Shipped/Picked up
		PHOTO REPRODUCTION PRICES Black and white prints (Prints are produced with industry standard Epson ink-jet printers on photo weight paper): up to 5" x 7": .... .... .... .... .... .... .... .... .... . $ .... 15.00 each 8" x 10": .... .... .... .... .... .... .... .... .... .... . $ .... 20.00 each 11" x 14": .... .... .... .... .... .... .... .... .... .... $ .... 30.00 each Reference Print of Scan (Preview Print): . . . . . . . . . . . . . . . . . . . $ .... . 1.00 each Scan to cd or email attachment (72 ppi suitable for previewing) . . . . $ .... . 8.00 each Scan to cd or email attachment (600 ppi requires permission to publish)$ . . . 20.00 each CD-ROM supplies charge .... .... .... .... .... .... .. $ .... . 4.00 per disk Rush Order (maximum of 5 items): . . . . . . . . . . . . . . . . . . . . . . double the standard price per item Postage and handling (up to 2 prints) . . . . . . . . . . . . . . . . . . . . . . . . . . $ .... . 2.00 Quantities above 2 ADD .... .... .... .... .... .... ... $ .... .. .50 per print *Preview copies are only available for previously scanned photographic images. North Dakota orders must include sales tax

One to five prints or digital images are normally produced within 3 weeks of receipt of order. Orders for more than 5 prints or digital images are considered special orders and must be scheduled by the photo archivist. Publication, exhibit, reproduction or other commercial use of photographic images held by the State Historical Society of North Dakota is prohibited unless authorized by an approved "Request for One Time Use of Photographic Image" from the STATE HISTORICAL SOCIETY OF NORTH DAKOTA. In addition, you must credit completely and as specified in the "Request for One Time Use of Photographic Image. Not all images available for reference use can be reproduced for use commercially, in publications or exhibits.

If you have questions or need assistance with this form, call 701-328-2091, Fax 701-328-2650 or write: State Historical Society of North Dakota, State Archives, 612 East Boulevard, Bismarck, ND 58505-0830

QUANTITY	PRINT SIZE	COL #	ITEM #	DESCRIPTION	COST
				Please Transfer Totals to Front