编号Ref. Noin LCS MH10-30 ___ 40-2015 ____.doc

編號Ref. No: ( ) in LCS MH10-30 ___ / 40-20/15 ____* 藏品複製申請表格 Application for Reproduction of Museum Materials 申請者： Applicant 機構名稱： Institution 電話號碼： 傳真號碼： 電郵 Telephone No. Fax No. E-mail 地址： Address 　　複製項目資料 Details of Reproduction　　　 博物館 編號 Museum Ref. No. 說明 Brief Description 數量 Quantity 照片 Prints 幻燈片Transparencies / 負片 Negatives 電腦掃瞄 Digital Scanning 視聽節目 Audio-visual Programme 複製權費 Reproduction Right Fee 黑白 (呎吋) b/w (Size) 彩色 (呎吋) Color (Size) 呎吋 (Size) 時段Time range 每項每次$1,000 $1,000 per item per usage 1. 2. 3. 4. 5. 6. 費用 (以現金/劃線支票/銀行本票繳付港幣淨額予「香港特別行政區政府」 Fees (Made payable by cash/ cross cheque / bankdraft to “ The Government of HKSAR” in net amount, Hong Kong Dollars) HK$(Materials) + (Rights) = (Total) (聲明Declaration (聲明須知：申請人如提出虛假聲明，則須負上侵犯版權的法律責任。 Note to Declaration: The applicant who makes a false declaration is liable for infringement of copyright.) I declare that the reproduced materials will be used for the following purpose: 作出版/刊載用途者，請說明 Please provide information for publication: 刊物名稱Title： 性質Nature： (出售/商業for sale/commerce (慈善for charity (免費派送free distribution 類型Type ： (書籍book (期刊periodical (小冊子pamphlet (雜誌magazine (錄影帶video (光碟CD ROM (網頁webpage (其他 others 日期Date： 申請人簽署Signature of applicant： (簽署前，請先閱申請須知。 Please read the Notes to Applicant before signing) 本館專用 For official use only Approval Fees Progress *Approved / Not approved CC(MH) / C(CSYSM): Date: HK$ By cash/ cheque/ bankdraft Bank : Cheque No Date: M.R. No Resource Centre Officer Payment received: Items ready: Delivery: 申請須知 Notes to Applicant 複製服務收費表 Fee of Reproduction Services 申請規條 Application Conditions 項目 Item 每項收費 (港幣) Charge Per copy (HKD) 申請者必須使用本表格以便本館處理有關申請。 Applicants must use this form for Museum’s handling of reproduction application. 申請者如需參閱圖片及視聽資料，請致電參考資料室2724 9009或27