Agreement Form – Toodyay Historical Society

Project Name

Collection Name

Interviewee First name - second name, initials *

Surname *

Role TOPIC *

(Prompt - my memory is of Show Days, Moondyne Festival, Business ownership)

Address *

Email *

Phone number

Year of Birth *

Date of Birth

Personal Profile - Relation to Toodyay

Please Enter The Details *

Name of organisation

Name of project

Place of interview

Date of interview *

The Interview will be preserved in the organisation’s collection and made available to the organisation’s staff/volunteers and members of the public subject to the following conditions (please select one): *

General Access with no restrictions on use of the Interview or the material in the Interview other than those normally imposed by the organisation on its users.

Restricted Access with the organisation to impose a restriction that the Interview or any part of the Interview will not be copied or published without my prior written consent.

Other Restrictions and Conditions. The organisation will use its best endeavours to ensure that the following restrictions are observed in any use of the Interview (attach appendix if insufficient space below):

If the organisation reproduces, publishes, broadcasts, transmits, performs or in any way at all makes the Interview available to the public then I will receive the following acknowledgement, where possible (please select one): *

My full name as set out above

No acknowledgement or disclosure of my name