Request to Use DCHS Images - Dutchess County Historical Society

Request for use of images in DCHS Collections

Name *

First

Last

Organization if applicable

Email *

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Brief description of image(s) and/or Catalogue No. if available

Please indicate type of use

Category of uses

FOR FILM VIDEO TELEVISION please indicate Producer, means of and geography for distribution. Date and time.

FOR DIGITAL ONLINE please indicate website or other digital location.

FOR PRINT please indicate publisher, publication title, date of issue.

FOR EXHIBITION indicate location, beginning and end time

IF FEES are involved you can pay by credit card here or mail check payable to DCHS PO Box 88 ~ Poughkeepsie NY 12602 *

Card Number

Security Code

Name on Card

Expiration/

Billing address (for credit card only)

Thank you for your interest in the Dutchess County Historical please add any comments here or contact us directly.

Name