Imaging Services Order Form Request Multiple Resources Please enable JavaScript in your browser to complete this form.THE MARYLAND CENTER FOR HISTORY AND CULTURE DEPARTMENT OF IMAGING SERVICES 610 Park Ave., Baltimore, MD 21201 | imagingservices@mdhistory.org | Fax 410-385-2105Please note: Fees apply. To view The Maryland Center for History and Culture’s fee schedule and terms of use, visit our Rights and Permissions page.CONTACT INFORMATIONName *FirstLastMaryland Center for History and Culture Member NumberNonprofit EIN/Tax IDAre you making your request on behalf of a company/organization? *YesNoCompany/Organization NameAddress *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Due Date Requested *Please note: Standard turnaround time is 14 business days after payment is received. Please confirm rush requests. Surcharges may apply.Service RequestedDigital Reproduction and PermissionImage Permission OnlyDigital Reproduction (Image file only, no permissions. Select this option for personal use.)For research/reference purposes only. This image will not be published in print or online in any way.Delivery MethodDigital DownloadSpecial Instructions (additional fees may apply)Special InstructionsPROJECT INFORMATIONIndicate N/A if a field is not applicable.Medium *BookEbookMagazine/CatalogNewspaper/Journal/BrochureAdvertisementExhibition/Display/PresentationWebsiteTelevision/Film Production/Streaming VideoBlu-ray/DVDOtherIf other, indicate medium here:Author/Designer *FirstMiddleLastTitle of Medium *Publisher Name *Publisher Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeExpected Date of Publication/Exhibit *Size of Print Run/Exhibit *Language *One languageAll languagesGeography *One continentWorldwideIs the use of the image intended for a book, magazine, DVD, or journal cover? *YesNoIMAGE REPRODUCTION INFORMATIONNumber of Images Requested123456Resource or Object ID *Author/ArtistFirstMiddleLastTitle/Description (page number if applicable)CollectionDate of ImageRequested File Type *TIFFJPEGImage #2Resource or Object ID *Author/ArtistFirstMiddleLastTitle/Description (page number if applicable)CollectionDate of ImageRequested File Type *TIFFJPEGImage #3Resource or Object ID *Author/ArtistFirstMiddleLastTitle/Description (page number if applicable)CollectionDate of ImageRequested File Type *TIFFJPEGImage #4Resource or Object ID *Author/ArtistFirstMiddleLastTitle/Description (page number if applicable)CollectionDate of ImageRequested File Type *TIFFJPEGImage #5Resource or Object ID *Author/ArtistFirstMiddleLastTitle/Description (page number if applicable)CollectionDate of ImageRequested File Type *TIFFJPEGImage #6Resource or Object ID *Author/ArtistFirstMiddleLastTitle/Description (page number if applicable)CollectionDate of ImageRequested File Type *TIFFJPEGSubmit
