Please print and complete this form and mail it to:

LHEF, Inc.
484 14th Street
Brooklyn, New York 11215


ORAL HISTORY (VIDEO/DVD/AUDIO) DONOR AGREEMENT
(for Art/Photography and Special Collection use separate forms)

Name of Donor: _______________________

Name of Collection (if different from Donor's Name): _______________________

Address: _______________________

_______________________________

City: ___________________________

State: _________    Zip: ____________

Date: _________


Phone Number: ____________

E-Mail Address: _____________
(if you would like to be informed of upcoming events)


Collection # _______________________________   (to be filled in by LHEF)

I agree to donate the recordings described below to the Lesbian Herstory Archives/Lesbian Herstory Educational Fund (LHEF, Inc.) to become its permanent property. All property rights of the material or objects donated are granted to LHEF. This material may be made available for viewing, listening and research, subject to restrictions that may appear below.

I understand that all responsibility to obtain publication or reproduction permission rests solely with individual researchers, not with LHEF, Inc. Researchers may make copies of these recordings for personal use instead of note taking.


Description of Recordings and Other Accompanying Material:
(Please use back of page if more space is needed).


Please Indicate:

LHEF (check one) may___ may not___ list my name and a general description this material on the LHA website. I understand that any restrictions that may appear below remain in effect.

Any copyright which the donor possesses to publish or reproduce this material in print, video, film, or other recorded format is reserved by the donor requiring written consent prior to each publication until death whereupon (check one):

      _______ It is assigned to LHEF, Inc.

      _______ Assigned at this time to LHEF, Inc.

      _______ Other (as stipulated below or on reverse)

Respondent Information:

Respondent Signature: _______________________

Address: _______________________

_______________________________

City: ___________________________

State: _________    Zip: ____________

Date: _________


Phone Number: ____________

E-Mail Address: _____________
(if you would like to be informed of upcoming events)


LHEF, Inc. may/may not (circle one) provide researchers with my address and phone number for publication permissions.



Interviewer Information:

Interview Signature: _______________________

Address: _______________________

_______________________________

City: ___________________________

State: _________    Zip: ____________

Date: _________


Phone Number: ____________

E-Mail Address: _____________
(if you would like to be informed of upcoming events)


LHEF, Inc. may/may not (circle one) provide researchers with my address and phone number for publication permissions.


Restrictions:
(Please use back of page if more space is needed).

Access to and /or duplication of this material is restricted as follows:




Display of this material by LHEF is restricted as follows:





Donor Signature: _____________________________________



Received By: ______________________________________       Date:________    (to be filled in by LHEF)

LHEF, Inc. seeks material from all lesbians. Access to collections is granted without regard to academic, sexual, or political credentials. All donations are tax-deductible.

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