Agreement Form

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): *
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): *