Reproduction application form

Please print the application form, complete, sign and send it to:

UCL Special Collections
Library Services
Gower Street
London, WC1E 6BT

Alternatively, you can fax the application form to +44 (0) 20 7679 5157

Surname: First name: Title:
Name and address of company/ publication   
Telephone: Email address
Images you require  
Do you wish to publish these items? No      Yes
What rights do you require? Single country/ language      World (please specify below)
Date of publication  
Proposed use of images  

Published in a Book:

Cover: 1/4 page      1/2 page      whole page     Inside book (any size)      Both cover and inside:  

Periodicals/ Newspapers - inside space rate:

Less than1/4 page      1/4 page      1/2 page     3/4 page      whole page      double page

Audio/ Visual

Televison: 1 use (plus 1 repeat)      5 years unlimited transmission      8 years unlimited transmission

DVD/ Video (one edition only)      CD (upto 10,000 units)      CD (more than 10,000 units)

Website 

Estimated print run

Less 2,000      2,000 - 5,000      5,000 - 10,000     More than 10,000   
Additional information:
Signature Date