Department of Special Collections

Manuscripts Unit

Notification of Intent to Quote from or Publish Manuscript Materials

I hereby notify Washington University Libraries' Department of Special Collections of my intent to quote from or publish the following materials that are part of the Special Collections:

(State specifically and in detail the manuscript materials or portions of manuscript material you intend to quote from or publish. If any images or transcriptions of manuscript collection materials are to be used as illustrations, provide an itemized list. Use an attached sheet if necessary.)

Collection name: ____________________________________________________________________________

Manuscript materials: ________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Please provide the publication information listed below:

Author/Editor:	Title:
Publisher:	Projected publication date:
Print run:	Projected retail price:

STATEMENT OF RESPONSIBILITY: I certify that the information on this form and any attachments is correct and that any publication of the requested materials will meet the conditions established by the Department of Special Collections, as listed in the Publication and Teaching/Education Policy. I am aware of my responsibility in the case of possible copyright infringement. Further, I agree to pay Washington University a use fee, if applicable, as stated below.

Signature:		Date:
Patron name (please print):
Address:
Phone:	Email:

WASHINGTON UNIVERSITY DEPARTMENT OF SPECIAL COLLECTIONS APPROVAL:

Name:	Title:
Signature:	Date:	Use Fee: