ALABAMA DEPARTMENT OF ARCHIVES AND HISTORY
P.O. Box 300100
Montgomery, Alabama 36130-0100

COPY FOR PRIVATE USE ONLY

I/we request permission to keep one copy for personal use only from the collections of the Alabama Department of Archives and History. I/we agree to abide by the conditions stated below:

CONDITIONS
1. I/we agree not to reproduce this item in any way, including, but not limited to, photocopying, photographing, publishing, or filming.

2. I/we agree not to advertise, display, or otherwise make public this item in a public setting of any kind without the express written approval of the Alabama Department of Archives and Histtory as executed through a PERMISSION TO PUBLISH CONTRACT.

3. Please list item(s), collection(s), or other materials which you are requesting to use privately. Give a full description if a photocopy is not able to be attached to this form.

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I/we agree to the conditions specified above.

SIGNATURE:______________________________________
NAME (print):______________________________________
ADDRESS:________________________________________
         ________________________________________
TELEPHONE NO.:________________________
APPROVED:_________________________________ ,Assistant Director for Public Services
DATE:____________________