Name ___________________________________________________________________________________
Affiliation ________________________________________________________________________________
Street Address ____________________________________________________________________________
City _____________________________________________ State ________ Zip _______________________
Home Phone ________________________________ Business Phone ________________________________
E-Mail Address (optional) __________________________________________________
Purpose of Research (check all that apply)
| ____01 State agency operations | ____02 Legislation |
| ____03 Genealogy | ____04 Military history |
| ____05 Student paper | ____06 Graduate thesis |
| ____07 Community history | ____08 Historic preservation |
| ____09 Archaeology | ____10 Printed publication |
| ____11 Illustrations | ____12 Legal proceedings |
| ____13 Property title search | ____14 Exhibit |
| ____15 Instructional use | ____16 Audiovisual Archives |
| ____17 Other (please specify): | ____________________________________________________ |
DECLARATION: I acknowledge that I have received, read, understand and will abide by the Archives and History Library rules as listed. I understand that violation of the rules is grounds for revocation of permission to use the library or Archives and History materials. For any publication, broadcast, film, exhibition, etc., in which this material is used, I will give credit as follows: "West Virginia State Archives." When a specific collection name is provided by Archives and History, that name will also appear in the credit line.
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