UIC Permission To Publish Form

Subject to the following conditions, I/We request permission to publish material reproduced from the University of Illinois at Chicago Library (UIC Library). Items to be published, as well as publication information, are listed in the bottom section of this form.

1. Permission is granted for one-time use only. Material may not be re-used without the written permission of the UIC Library. The User must complete a separate permissions form for change of use; change in format; sale, transfer, or loan to a different user, publisher, distributor, company, corporation, etc., either in the United States or elsewhere; change in agreed upon distribution; change in location; or any other deviation from the uses designated below.

2. Permission to publish is contingent upon the acknowledgement of this request from a UIC representative.

3. The UIC Library does not claim to control the rights of reproduction for pictorial materials in its collections. The publishing party assumes all responsibility for clearing production rights and for any infringement of the U.S. Copyright Code.

4. The publisher agrees to send the UIC Library a copy of the publication(s) containing the image(s) used. In the case of motion pictures, slideshows, videos, exhibits, or any other such work, the publisher undertakes to send still photographs or photocopies of the title frame and frame showing picture credits.

5. If non-profit, the User certifies that all funds it collects from fees, charges, royalties or other income from its use of the material obtained from the UIC Library shall be used for non-profit purposes.

6. Citations should consist of the following for each image:

Photograph identification number (if known)
Collection or file name (required)
Special Collections & University Archives, University of Illinois at Chicago Library (required)

Date of Request:
Name: *required
Address 1: *required
Address 2:
Address 3:
City: *required
State: *required
Zip: *required
Telephone: *required

E-mail: *required
Format and Distribution Information:
Print Media (book, article, newspaper, etc.)
Book Magazine/journal Catalog/brochure/flyer Newspaper article
Cover Thesis Personal publishing (1000 or fewer copies)
Number of copies or circulation size:
Film/Video Production
Standard/non-standard TV - Local Non-Broadcast
Standard/non-standard TV - National Non-Broadcast Instructional
Standard/non-standard TV - World Wide Home video sales/rental
Non-theatrical distribution Theatrical
Digital Publishing
CD E-Books Online Exhibit
DVD World Wide Web
Other Uses
Advertising Exhibits Commercial Display
Office Decor Commercial Product Presentation
Theater/Live Event Classroom Project
Name of Author(s):
Date of Publication or Display:
Images to be Published or Displayed, Including Photo ID Number and Collection Name:
(if more than 10, please submit additional requests)
1. 2.
3. 4.
5. 6.
7. 8.
9. 10.

Print this form for your reference before you submit it.