Your story (oral history) is valuable for people doing research
on the topic of ____________________,
and we would like to incorporate it into the Oral History Archives
of California State University, Long Beach. If you are in agreement,
please complete/sign the form below.
I hereby give to the ORAL HISTORY PROGRAM and/or the UNIVERSITY
ARCHIVES for such scholarly and educational uses and purposes
as the Director(s) shall determine, the following tapes of the
interviews recorded on (dates):___________________________________________________________.
Unless otherwise specified below, I place no restrictions on non-commercial
access to and use of the interviews:
Name:________________________________ _______________________________________
(Please print) Phone/email
Address:___________________________________City:________________Zip:
_________
__________________________________________ _____________________
Signature of interviewee Date
____________________________________ ____________________________________
Name of interviewer (Please Print) Phone/email
Address:___________________________________City: _______________Zip:
_________
Signature of interviewer: ________________________ Date:_________________
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I wish to place the following restrictions on the use of the recorded
interviews: Please check and initial those restrictions you wish
to place on the use of your interview(s):
______ I wish to be identified by the pseudonym ________________________
______ I wish to restrict access to the materials until (date):
_______________
______ I wish to close specified portions of the interview, as
noted on the attached document
______ I wish to restrict access to the materials to on-site use
(i.e. exclude electronic distribution)
______ Other (specify):
I/we agree to abide by these restrictions::
Signed by: _______________________________________ Date:___________________
Position _____________________________ Phone/email:_________________________
If you should wish to make inquiries at any future date about
the disposition of your interview, feel free to contact the Director
of the Oral History Program (562-985-8765).