MEDIA PERMISSION REQUEST AND AGREEMENT FORM
Please print clearly. Return completed and signed form to pahma-mediapermissions@berkeley.edu
1. Requestor’s Contact Information
Name
Company
Address
City
Telephone
Email
State
Zip code
2. Materials Requested
⃝ Image(s)
⃝ Film
Museum (PAHMA) catalog # and Cultural Group:
Description:
3. Usage Rights
Category of Use:
⃝ RESEARCH ONLY
Respond to all questions appropriate for your project. Please print clearly.
⃝ PRINT: ⃝ Textbook ⃝ Catalog ⃝ Journal ⃝ Magazine ⃝ Exhibition
Publisher
Author/Editor
⃝ FILM, VIDEO, DVD & TELEVISION
Producer(s) Name(s)
Channel/Networks
Scheduled Airing Date(s) & Time(s)
⃝ ELECTRONIC
⃝ CD-ROM ⃝ Website URL
⃝ Other Digital Delivery please specify
⃝ OTHER
Please explain
4. Rights Requested
⃝ North American/English ⃝ Worldwide/one language ⃝ Worldwide/all languages
Title (book/product/program/exhibition)
Publication/Distribution Date
Print Run/No. of Units: ⃝ <3,000 ⃝ 3 – 10,000 ⃝ >10,000
Image Type:
Reproduction Size:
⃝ Color ⃝ B&W
⃝ Cover ⃝ Spread ⃝ Full Page ⃝ ½ Page ⃝ 1/3 Page ⃝ ¼ Page
pahma@berkeley.edu • (510) 642-3682 • hearstmuseum.berkeley.edu
103 Kroeber Hall • University of California • Berkeley, CA 94720-3712
5. Payment Information
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Bill to:
Ship to (if different from billing address):
Name
Name
Company______________________________________
Company______________________________________
Address_______________________________________
Address_______________________________________
City__________________________________________
City__________________________________________
State
Zip
State
Zip
Telephone_____________________________________
Telephone_____________________________________
Email_________________________________________
Email_________________________________________
>UCB Departmental Chart String:
>UC Departments please indicate your BFS Chart String so that we can charge your unit by Journal Entry.
Licensee agrees to pay to PAHMA all photographic charges and postage and handling fees in accordance with PAHMA’s
posted fee schedule. Licensee agrees to send to PAHMA one copy of the finished book.
⃝ Invoice me
Licensee shall pay to PAHMA the full amount of all fees, due on receipt of the PAHMA’s invoice. Make check payable to
Regents of the University of California, include reference to the PAHMA invoice number, and deliver to:
Media Permissions
Phoebe A. Hearst Museum of Anthropology
University of California at Berkeley
103 Kroeber Hall #3712
Berkeley CA 94720
⃝ Charge my credit card: ⃝ VISA ⃝ MasterCard
Card no.
Name on card
Signature
Expiration
6. Permission
The Phoebe A. Hearst Museum of Anthropology, University of California at Berkeley, grants the one-time, nonexclusive
right to the undersigned Licensee to reproduce the materials indicated in this agreement for the usage indicated herein.
The granting of rights for PAHMA materials is contingent on the payment of all fees. Payment in advance of publication
or production of product is required. By signing this form, the Licensee confirms the accuracy of the above representations and agrees to comply with the terms of this document, and any additional terms attached to this form by PAHMA.
If the request is approved, a fully executed copy of this agreement will be returned with an invoice and the materials for
which the permission has been granted.
All reproductions must show the following credit:
⃝ Copyright © Phoebe A. Hearst Museum of Anthropology and the Regents of the University of California,
Photography by
, (Catalog No.
⃝ Courtesy of the Phoebe A. Hearst Museum of Anthropology and the Regents of the University of California,
Photography by
, (Catalog No.
)
)
I have read and understood this agreement and accept
its terms and conditions
For Phoebe A. Hearst Museum of Anthropology,
University of California at Berkeley
Licensee (please print)
⃝ PAHMA DIRECTOR ⃝ AUTHORIZED PAHMA
Title
Name
Signature
Signature
Date
Date
Return completed and signed form to pahma-mediapermissions@berkeley.edu
7. Terms and Conditions
PERMISSION
This document identifies the following: (A)
the intellectual property – images, data or
text – (“Property”) in the possession of the
Phoebe A. Hearst Museum of Anthropology
(“PAHMA”); (B) the requestor (“Licensee”)
who seeks to use the Property; and (C) the
Licensee’s intended use of such Property.
When signed by PAHMA, PAHMA grants to
the Licensee the right to reproduce the
Property, subject to the following
conditions: (a) the right is nonexclusive and
non-transferable; (b) the right is subject to
the terms and conditions and
representations set forth in this entire
document; and (c) the right is subject to any
fees or other attachments that shall be
deemed an integral part of this agreement.
WARRANTY AND ACCEPTANCE
Licensee hereby warrants the accuracy of
the representations made in this
agreement. Licensee agrees to publish the
Property only in accordance with the terms
of this agreement and to comply with all its
terms. Licensee agrees that each
permission is for one time use, and any
further or subsequent use of the Property is
subject to the execution of an additional
permission agreement and fees. Licensee
further agrees that it shall not alter the
Property without the express written
permission of PAHMA.
DELIVERY
PAHMA will endeavor to deliver the
requested Property with four (4) weeks of
the acceptance of Licensee’s request.
Prepayment is required. The Property will
be emailed or sent First Class postage,
unless Licensee specifies and agrees to
pay for special delivery. Purchased physical
media of the Property need not be returned,
unless specifically requested; in any case
the Property may not be reproduced again
without an additional permission
agreement.
RIGHTS AND COPYRIGHT
PAHMA shall at all times retain all rights to
the Property, including copyright where
applicable, and Licensee agrees to exercise
due care in the protection of such rights.
Licensee agrees that no part of the
Property may be reproduced in any form
without PAHMA’s express written consent,
and that any reproduction of the Property
must include the credit line indicated in this
agreement. Licensee agrees to undertake
other such measures as may be reasonably
requested by PAHMA to assist in the
tracing of any unauthorized copies. If
PAHMA does not hold the copyright to the
Property, Licensee agrees to obtain the
permission of the copyright holder prior to
publication, to pay any necessary fees in
connection with such permission, and to
hold PAHMA harmless in the event that
such permission is not obtained.
TERMINATION
In the event the Licensee shall fail to keep,
perform, or observe the terms and
conditions of this agreement, including
prompt payment of royalties, PAHMA shall
have the right to terminate the permission
agreement on fourteen (14) days’ written
notice by Certified Mail, Return Receipt
Requested, to Licensee. During these
fourteen (14) days, Licensee shall have the
right to remedy such failure(s). When
PAHMA receives evidence of such remedy,
the termination notice shall have no further
force or effect.
advertising without PAHMA’s prior express
written consent.
ASSIGNMENT
The Licensee shall not assign this
permission to any third party without the
prior express written consent of the
PAHMA, and any purported assignment
without such consent shall be void.
RELATIONSHIP OF THE PARTIES
Licensee is an independent contractor and
nothing contained in this permission shall
be deemed or interpreted to constitute
Licensee to be the agent or legal
representative of PAHMA for any purpose
whatsoever. Licensee is not granted any
right or authority to assume or crate any
obligation or responsibility, expressed or
implied, on behalf or in the name of
PAHMA, or to bind PAHMA in any manner
or fashion whatsoever.
ENTIRE AGREEMENT AND
AMENDMENTS
This permission agreement contains the
entire agreement between the parties. No
amendments or modifications to this
permission agreement shall be effective
unless made in writing and signed by an
authorized representative of both parties.
LAW
This permission agreement shall be
construed in accordance with and governed
by the laws of the State of California.
USE OF NAMES
Except for publication in recognized
research journals or otherwise in
connection with other academic or scholarly
purposes, including the references required
under this permission agreement, Licensee
shall not employ or use the names Phoebe
A. Hearst Museum of Anthropology or
University of California at Berkeley in any
publications, promotional materials, or
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