This form is required to be completed when permission is sought to use any material contained within this website for purposes other than private research or study. The completed form should be submitted to The Secretary, Kurrajong-Comleroy Historical Society, PO Box PO Box 111, Kurrajong NSW 2758, Australia, or scanned and emailed as a PDF to [email protected]. If you are submitting a purchase order to the Society for photographs or back-issues of The Millstone then the completed form may also accompany your purchase order. Print this blank form.

1. I/We request permission to publish or avail for public display or reward the following item(s) to be obtained from the Kurrajong-Comleroy Historical Society's website collections:
   
   

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2. Details of how this/these item(s) will be used by me/us are as follows:
   
   

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3. I/We agree to include with the used item(s) the following acknowledgements to the copyright owner(s):
   •  KCHS Photograph Number (applicable for photographs);
   •  KCHS source document (applicable for documents);
   •  Copyright owner; and
   •  Acknowledgement: "Reproduced with permission from the Kurrajong-Comleroy Historical Society."
   
   
4. I/We understand and agree to the following conditions with respect to the use of the item(s):
   •  Compliance with the requirements of the Copyright Act 1969 (Cwlth) and the Copyright Amendment (Digital Agenda) Act 2000 (Cwlth) is my/our responsibility and the Kurrajong-Comleroy Historical Society will not be held liable for any breach by me/us under these Acts regarding use of the item(s); and
   •  The details of the item(s) supplied by the Kurrajong-Comleroy Historical Society are done so in good faith and the Society does not guarantee the accuracy of the information

Signed .......................................................................       Date ..............................................

Print name(s) ..........................................................................................................................

Organisation ...........................................................................................................................

Address .................................................................................................................................

Telephone ..................................................       Email .............................................................