Item Request and Fee Schedule

Applicant Information

Name of Applicant *

Organization or Agency *

Address *

Telephone Number *

Email Address *

Items Requested

Items Requested Repeater

I/We request permission to publish, exhibit, or broadcast the following item(s) where the copyright holder is the Eccles Health Sciences Library:

	Item Description *	Collection Name *	Link or Filename *
1
1

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Usage Description

Description of Intended Use *

Author or Producer

Publisher or Production Company

Type of Usage *

*required | Check all that apply.

Commercial Use
Non-profit
Personal
Educational

Format of Use *

*required | Check all that apply.

Certification of Application *

*Required

I attest the information contained in this request is accurate and agree to the terms outlined in the usage policies located at: https://library.med.utah.edu/publishing/image-request-and-fee-schedule/

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EHSL

Eccles Health
Sciences Library

Spencer S. Eccles
Health Sciences Library

EHSL Digital Publishing and Collections

The Eccles Health Sciences Library Digital Publishing Group can provide reproductions of photographs, documents, audio-visual materials, and other materials within our collections.

Request Form