[Your Details]

[Image Details]

I declare:

1. I  have not previously been supplied with a copy of the same material by you or any other librarian.
2. I will not use the images except for research or private study and will not supply a copy of it to any other person; and
3. To the best of my knowledge the work has not been published before the document was deposited in your library and the copyright has not prohibited copying of the work.
4. If I wish to reproduce or publish any of the images I must first obtain written permission to do so from the copyright holders and Dr Williams’s Library.

I understand that if the declaration is false I will be liable for infringements of copyright.

Data Protection Act 1998:
I confirm that these photographs are for use with my personal research only and that any images that are Personal Data, as defined by the act will be stored securely and not disclosed to unauthorised third parties.

Signature

Date:

This must be the personal signature of the persons making the request. A stamped or typed written signature, or signatures of an agent, is not acceptable.