Office use
Photographic and Digital Image Order Form
No:
Sent:
Please fill in the details clearly to ensure delivery of the correct images.
To place your order save this file and, email to [email protected],
fax to (07) 3840 7795, or post to Document Supply, Collection Access, State Library of
Queensland, PO Box 3488, South Brisbane, QLD 4101
Note that payment is required in advance. Please complete the Credit Card Payment form or make out cheque in
Australian dollars, payable to the Library Board of Queensland, or pay in person at The Library Shop.
Name:..................................................................................................................................................................
Address:.............................................................................................................................................................
State: ………………Postcode:...................Telephone:.......………...................................................................
Email:………………………………………………………………………………………………………………………
I state:- (please tick which is applicable)
I require the image/s for the purpose of research or study and will not use it/them for any other purpose
I wish to reproduce the image/s in a………………………………………………… .( e.g. book, display etc)
Signed:………………………………………………………………………
Date:
/
/
Conditions for Reproduction
1. Copyright clearances, where necessary, are the responsibility of the applicant who shall indemnify the Library
Board of Queensland against any action whatsoever taken by the copyright owner(s) against the State Library
of Queensland arising in any way whatsoever from the publication of the Photographic Materials by or on behalf
of the Applicant.
2. The State Library is acknowledged, and the negative number is displayed with the illustration.(e.g. State Library
of Queensland, neg no. 12345)
3. The State Library of Queensland, Queensland Memory, receives a complimentary copy of the item in which the
image is published for the collection where possible.
Negative Number
or Identifier
Description/date of items
TO PLACE ADDITIONAL
ORDERS SEE REVERSE
Collect
Digital Format
(tiff or jpeg) on
CD or email
Cost
(AU$)
Cost of CD (if required)
Delivery Instructions (please circle)
Email
Print Size eg A4
(matte or semigloss)
Post
I require RUSH service and authorise State Library to double
the total (not including CD and delivery costs)
Delivery (if required)
TOTAL (AU$)
Staff Initials
………………….
State Library respects your privacy. Personal information we collect is used only for our internal activities and functions (Libraries Act 1988) and will not be
discussed unless required by law.
Photographic and Digital Image Order Form
Description/date of items
Negative Number
or Identifier
Print Size eg A4
(matte or semigloss)
Digital Format
(tiff or jpeg) on
CD or email
Cost
(AU$)
Please calculate all costs
and include in overall
TOTAL
State Library respects your privacy. Personal information we collect is used only for our internal activities and functions (Libraries Act 1988) and will not be
discussed unless required by law.
Photographic and Digital Image Order Form
Credit Card Payment
Card Holder’s Name………………………………………………………………………………
Card Type:
Visa
Mastercard
American Express
Card Number:
Expiry Date:
/
Amount:
Receipt Required:
Yes
No
Your credit card details are not retained on file, but are securely disposed of once your payment has been
processed.
State Library respects your privacy. Personal information we collect is used only for our internal activities and functions (Libraries Act 1988) and will not be
discussed unless required by law.