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2. Thank you for your interest in the Riverview Hospital Artifact Collection.

   Please complete and submit the form. Your information will be retained on file.

4. Applicant Name
6. Organization
7. Title/Role
9. Mailing address
11. Email
12. Phone
14. As the applicant, I am requesting

    1. Permission to examine item(s) in the collection for the purpose of examination, study, and/or research.
    2. Permission to borrow item(s) from the collection for the purpose of exhibition.
    3. Permission to photograph item(s) in the collection for the sole purpose of research or study. I agree that my photographs will not be used for publication, exhibition, or commercial use.
    4. Permission to photograph item(s) in the collection for the purpose of publication, exhibition, or commercial use. I understand that gaining permission to photograph does not constitute agreement for photographic use. I agree to submit a request to publish photograph(s) on a separate form. I understand that I must receive approval to publish photograph(s) prior to publishing any photograph(s).
    5. Other
16. Please specify other
18. Project description
20. List of item(s)

    Please list accession numbers of individual items if they are of significance.

22. The applicant agrees to indemnify and hold harmless the City of Coquitlam, its employees, students and volunteers for all claims and damages, including all legal fees and disbursements and other professional fees, howsoever arising, directly or indirectly, under the Agreement.

    Conditions:

    1. The City of Coquitlam retains supervisory responsibility for the item(s).
    2. The City of Coquitlam reserves the right to restrict access to the collection for any reason. Access may be denied or terminated if use is deemed unsuitable or inappropriate.
    3. Supervision by the Conservator or designate may be required for physical access to an item in the collection.
    4. All costs related to access the collection will be the responsibility of the applicant. An applicant will be notified of any fees prior to accessing item(s).
    5. Item(s) shall not be removed from the designated viewing area except with the approval of the Cultural Services Manager or designate.
    6. Permission to examine item(s) does not automatically include permission to photograph the item(s).
    7. Permission to photograph must be confirmed prior to photographing the item(s).
    8. Approval to access / permission to photograph does not constitute approval to publish photograph(s).
    9. An Agreement for Photographic Use form must be submitted separately. The applicant must receive written approval prior to publishing photograph(s).

    I have read and agree to the conditions and understand that failure to comply with these conditions may result in the denial of future requests for reproduction.

24. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
26. Electronic Signature
28. Freedom of Information and Protection of Privacy Act*

    I understand by submitting this form I am consenting to the collection, storage, use and disclosure of my personal information for the purposes of the Riverview Artifacts Collection Program in accordance with the Freedom of Information and Protection of Privacy Act. I understand that my personal information will be disclosed to a third-party service provider (i.e. website host Civic Plus) located in Canada for the purpose of processing your request. If you have questions or concerns about the collection of your personal information, please email Hilary Letwin, Cultural Services Manager .

    1. I understand
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30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field