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PHOTO REPRODUCTION ORDER/ <br />APPLICATION FOR PERMISSION FOR SPECIFIED USE <br />Lane County Historical Museum, 740 West 13th Avenue, Eugene, OR 97402 <br />Phone: (541) 682 -4242 Fax: (541) 682 -7361 <br />Applicant Kathe rine Lieberknecht <br />Company Fairmount Neighborhood History Project <br />Address 1865 Villard Street <br />Eugene Oregon 97403 <br />Phone (541) 914 -4787 Cell <br />Intended Use For publication in Fairmount Neighborhood History booklet <br /># of ' Glossy/ Reproduction <br />conies Photo # Description Size Matte Fee <br />11 digital images on CD of Fairmount neighborhood photos @7.50 each, plus 2 CDs at $5.00 each <br />GN274 GN566 <br />GN282 GN569 <br />GN284 GN571 <br />GN558 Copy negative for GN571 <br />GN559 GN576 <br />GN562 GN4336 <br />J <br />�I <br />0 0 Total Paid: $119.00 <br />A lp $20.00 to be refunded for <br />duplicated order <br />GN566 �,pc <br />7AL <br />The applicant agrees that this permission is subject to the conditions listed oi�i t e back this form and further agrees to <br />promptly pay all applicable fees. <br />Please complete, sign, and return both copies, to Lane County Historical Museum. A countersigned copy will be returned to <br />you when permission is granted. <br />Signature ofApplicat <br />Print Name and Title <br />Signature of Museum <br />Order #862 Payment Received $119.00 Date . 02/22/2011 <br />740 W. 13th Ave Eugene, Oregon 97402 541.682.4242 tel 541.682.7561 fax' <br />www.lanecountyhlstoricalsociety.org <br />