Los Californianos Picture Library                       Member Submittal & Release Form

Member Name: _________________________________   #: _________   Phone:(      )__________ Date:  ___/___/___

 

      Address:__________________________________________________    Email:__________________

 

­        Please list and describe the Documents or Pictures submitted to the Picture Library:

 

 

Picture/Document Title

Description

(event, occasion, date, place, names, anecdote)

Picture

Source/Origin

PID

1

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

®   Please Sign: 

 To the best of my knowledge the photographs listed above came from the indicated sources. 

                                                                                                                                                Submitter’s Signature

¯  Please  select  the Purpose(s) you want to DISALLOW regarding these pictures:

 

Purpose          

 

Unrestricted Use

 

Personal Use by Other members

 

Printed Newsletter

 

Printed in Website

 

Individual Research

 

Digital Distribution

 

Public Exhibit

 

Printed Material

 

Commercial

 

Board & Committees Internal Use

 

Non-Profit Historical, Research, Education

 

 

°   For the cases you disallowed, would you like to be notified on a case by case basis?

       ð Yes ð No

±  Please Select Delivery Option  

                            

 

Email 

 

FREE

Snail Mail

$1.00

 Next Meeting

$0.40

 

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