Transcript request of authorisation

(According to Law no. 42/2004 - art. 108).
The authorisation is requested by:
First name……………………………..Surname.........…………………………………………………………
Address:
…………………………………………………………………………………………………………………..
Postcode.........………… City ……………….Country…………………………………………………………
Telephone…………………….Fax................................................ e-mail………………………………………
Tax Code………………………………………………………………………………………………………...
Intracommunity VAT number……………………………………………………………………………….......
for publishing the following picture:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
owned by the Pinacoteca Civica “F. Podesti” or Galleria d'Arte Moderna or Museo della città di Ancona.
I ask the following request:
• digital copy
• re-using an already-possessed image
• other
For:
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−
−
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• Personal use or study
• publication:
title: ….........................................................................................................................................................................
in one language with a print run of …. …………….and a cover price of € ………………………………...............
in multiple languages
in a periodical of a scientific nature
for reprinting with the same editor
for free distribution
• or publishing on an internet site
• for publishing in informative publications (cards, depliants, brochures, etc.):
for free distribution _ for sale at a price of…euro)
other (specify) …......................................................
Date __________________
PINACOTECA CIVICA “F. PODESTI”
Vicolo Foschi 4 - 60121 Ancona
[email protected]
[email protected]
Tel. 071 2225001 Fax 071 2225075
Signature __________________
DIREZIONE CULTURA
Palazzo Camerata – via Fanti 9
[email protected]
MUSEO DELLA CITTÀ
Piazza del Plebiscito – 60121 Ancona
[email protected]
Tel./Fax 071 2225037