Casa de Balboa, 1649 El Prado, Balboa Park CA 92101 Mailing Address: SDHS Photo Archives, PO Box 81825, San Diego, CA 92138
Telephone: (619) 232-6203 ext.127 Fax: (619) 232-6297 See Archive Hours
REQUEST FOR REPRODUCTIONS or APPLICATION FOR PERMISSION TO PUBLISH
Name of applicant: ____________________________________________________________________________________
Organization or agency (if appropriate): ____________________________________________________________________
Address: ____________________________________________________________________________________________
City, State, Zip: ______________________________________________________________________________________
Phone: ___________________________________________________ Fax: ______________________________________
Intended Use of Material:
___ These materials are for personal research and will not be copied, reproduced, or publicly displayed
___ These materials are for public display at: _________________________________________________________________
Author/Director/Producer: _________________________________________________________________________________
Title or description of use: ________________________________________________________________________________
Publisher: _____________________________________________________________________________________________
Projected date of publication: _____________________________________________________________________________
Format: ___Book ___Magazine ___Film/Video ___Advertisement ___School project/paper
___CD-ROM/multimedia (single user) ___CD-ROM/multimedia (multiuser/network)
___Other: ___________________________________________________________________________________________
Estimated size of edition (number of copies/size of market): _____________________________________________________
SHIP VIA: ___Customer will pick up ___US Postal Service ___FedEx: your account #______________________________
Statement of responsibility: I certify that the information on this form is correct and I accept the conditions of use.
I am authorized to enter into this agreement on behalf of the above named organization.
Signature of Applicant: ______________________________________________Date: ______________________________
Material Requested (Payment in full required before order will be processed)
Negative number / description: 
Quantity: Size: Cost:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
___Customer will pick up order OR SHIP: ___Via US Postal Service ___FedEx: Customer account #___________________
Total amount paid: ________ ___ Enclosed is my check (payable to the San Diego Historical Society)
___Visa ___Mastercard ___Am Expr Card # ____________________ Signature:____________________ Expires:_______