Client Contact Information Name:
Business Name:
Street Address:
City:
Province:
Postal Code/Zip Code
Phone Numbers:	e.g. (555) 555-5555
Fax	e.g. (555) 555-5555
E-Mail

I am creating the following project:

Exhibit or Display
Multimedia (CD ROM, DVD, video)
Publication (printed matter)
Website (internet/intranet)
Broadcast (radio, television, film)
Other   - Please describe

Please provide the title or a description of the project. For exhibitions or displays, please include the name and location of the gallery, museum or public space. For broadcasts, please provide the details of broadcast. For web sites, please provide the URL.

Project Details

I would like permission to use the following, as listed below:

Architectural drawing

Film, video, sound recording

Map or plan

Photograph or Documentary Art

Published material

Textual record

Reference Code (From back of copied document or Records Request Slip)	Title/Description of File or Item	Date of Record(s)

See below to add additional items.

On completion, please
and your response will be directed to the appropriate archivist.

This form is also available in pdf format if you would prefer to print that out and mail or fax in your request. Please send it to the address below.

Archives of Ontario
134 Ian Macdonald Blvd.,
Toronto, Ontario
M7A 2C5

Note: Permission requests are for one time use only. If you wish to re-issue, re-broadcast or re-publish, please submit another request form.