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Image Permission Form

Sample Letter Requesting Permission to Use an Image for Classroom Use


Today’s Date: _________________________________________________________


Printed Name of Right’s Holder: _________________________________________


Description and/or Title of the Gift: _______________________________________



Pursuant to the provisions of THE COPYRIGHT ACT OF THE UNITED STATES OF AMERICA, TITLE 17 OF THE US CODE, I, the undersigned, authorize Visual Resources Center, the Center for Teaching and Learning, and Doherty Library the non-exclusive rights to duplicate, distribute, create derivative works, publicly perform and publicly display the images listed either below, on the back of this authorization, or on an attached sheet through any analog and/or digital means, for any and all educational uses at Centre College. Furthermore and unless otherwise specified by the undersigned, the rights holder’s name and copyright date will be associated with any and all public displays and performances, derivative works, duplications and distributions.  It is understood that these images and the intellectual property contained therein are owned solely by the undersigned.


By signing below, I agree that Centre College may use any or all analog and/or digital duplicates created by the Visual Resources Center for the following purposes:


• Traditional face-to-face teaching

• Synchronous and asynchronous teaching through but not limited to the following:

o Storage on and retrieval from a University server for educational purposes

o Asynchronous and synchronous Internet courses

• Research

• Scholarship and scholarly activities

• Criticism and commentary

• Multimedia projects

• Library catalogs


The Visual Resources Center, CTL, and Doherty Library cannot authorize publication of these images. Publication of these duplicates requires permission from the owner.


Signature of Rights Holder __________________________________________________________


Signature of Visual Resources Center Curator __________________________________________