Requestor's Name

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Address

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What items are you requesting permission to publish or display?

Please be specific and provide the correct citation for the material as it appears in the online catalog and will appear in your publication or display.

Title/name of work/website in which item(s) from LSU Libraries Special Collections will be published

Item(s) will be used in...

(Please check all that apply.)

Format will be...

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If paper-based and/or cd/dvd, please indicate how many copies of each will be available for distribution.

Who is the intended audience?

Content will be available for Free Fee

If fee-based, what will it cost?

Name of Publisher or Website Owner

URL (if applicable) for Website

Projected Date of Publication

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