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ARCHIVES & SPECIAL COLLECTIONS

Conditions of Use Agreement for Archives and Special Collections

I hereby request permission to examine the manuscripts, photographs, or other materials listed below for
the following purpose (a specific statement is required, example: dissertation research, future book publication):

____________________________________________________________________________________

I understand that permission to examine a manuscript or photograph, if granted, does not include permission
to publish the contents of the manuscript, photograph, or any excerpt there from, at any time. Permission to
publish, or otherwise publicly use, must be specifically indicated below by a designated employee [Director of
Charles W. Chesnutt Library or his designee], as to the manuscript, excerpt, oral history, or photograph, to be
used. I agree to abide by the Director or designated employee's decision.

I understand further that the University makes no representation that it is the owner of the common law
copyright or literary property in any unpublished manuscript or photograph, and that wherever applicable,
permission to publish must also be obtained from the owner of the copyright (the owner or his transferees,
heirs, legatees, or literary executors). If this application includes a request for reproduction of any photograph,
manuscript, or excerpt listed below, I agree that the reproduction is to be made solely for the purposes
indicated. The reproduction will not itself be reproduced or transferred to any other person or institution.

In consideration of my being granted permission to examine or reproduce any photograph, manuscript, or
excerpt on the terms set forth hereby, I agree to indemnify and hold harmless the University, its officers,
employees, and agents from and against all claims made by any person asserting that he/she is an owner of
the common law copyright or literary property.

Permission is hereby given to the undersigned to use the following item(s), under the stated terms and
conditions, provided that publication use credits the collection as follows (name of the collection):

_____________________________________________________________________________________________

___________________________________________________________________________________________,

Charles W. Chesnutt Library, Archives & Special Collections, Fayetteville State University.

Any subsequent use requires additional authorization.

Purpose of Use (examples: for book publication, dissertation research, etc.):

____________________________________________________________________________________

____________________________________________________________________________________

Description or Identification of Item(s) Box or Container Number/Folder Number/Item Number:

____________________________________________________________________________________

Special conditions, stipulations, other notes on use:

____________________________________________________________________________________

Print name: _________________________________________________________________________

Phone Number and Email: _____________________________________________________________

Permanent address:___________________________________________________________________

_____________________________________________________________________________________

User signature: ______________________________________________ Date: ____________________

Designated authorization by: ___________________________________Date: _____________________

Director of Charles W. Chesnutt Library:__________________________Date:______________________

(rev January 2005 jsw)

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Charles W. Chesnutt Library, Fayetteville State University, Fayetteville, N.C. 28301
Page Maintained By: Jan S. Whitfield jwhitfield@uncfsu.edu
Last Updated: 1/24/05
Copyright 2003-2005