RIKEN Borrowing and Reproduction Request Form
Date:

ApplicantName of person in charge (applicant):
Company name:
Address:
Tel.:
Fax:

Section/Division:
Postcode:E-mail:What material(s) do you want to reproduce or borrow?
Description of the materials:
Types of materials (circle the appropriate item or items)(1) Printed material(2) Photograph (negative, positive, or electronic file)(3) Part of the RIKEN website(4) Display item(5) Microfilm(6) Other: __________________________URL etc.:
Why do you want to use these materials? State the document or publication in which youplan to use them, the purpose, and the period for which you want to use them.
Title of document:
Purpose of use:
Period of use:
How do you want to use these materials? If your answer is (1), (2), or (3), circle “all” or“part”.
(1) Reprinting (in an article or magazine or on a website) of all / part of the materials(2) Borrowing of all / part of the materials(3) Copying and distributing ____ copies of all / part of the materials(4) Other:
Conditions of useApplicants (persons requesting permission to reproduce materials) must obey the following rules.
1. Take care not to damage or lose the materials.
2. If rights to the materials belong to a third party, get permission to use the materials from thethird party.
3. Use the materials only for the purpose described above, and do not lend or give the materials toany third party.
4. Use the materials only once, not repeatedly or continuously.
5. Specify clearly that the materials are provided by RIKEN, or specify the source clearly.
6. Provide to RIKEN one copy of the newspaper, magazine, book, or video recording of the TV
program, or one copy of the part where the materials are used and the part where RIKEN iscredited.
7. Do not trim photographs or write captions or explanatory text for them in such a way as toconvey a different meaning from the original photograph.
8. Return borrowed materials by the date on which they are due to be returned, or as soon as thework is finished. (Due date:.)9. Explain the contents of the publication in which the materials are used, if requested by RIKEN.
10. RIKEN takes no responsibility for any damage or loss that may result from the reproduction orborrowing of its materials, to the party that uses the materials or to any third party.
11. The reproduction or borrowing of the materials must cause no damage or loss to RIKEN.
12. Issues not specified in this list shall be specified elsewhere.
13. Other:------------------------------------------------------------------------------------------------------------------------Date:To:
You are permitted to borrow and reproduce the materials as described above.
RIKEN Advanced Institute for Computational Science, Office for Research Communication
7-1-26, Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Hyogo, Japan
Tel: +81-78-940-5829 Fax: +81-78-304-4964 e-mail: aics-koho@riken.jp

RIKEN Borrowing and Reproduction Request FormExample
Date: 2006 / 12 / 15Applicant
Name of person in charge (applicant): Boris Korey
Company name: Hill Pharmaceuticals
Section/Division: Publications Office
Address: Hill Building, 33 Xxxx Street, Xxxxx City, Xxxxx
Postcode: 000-0000
Tel.: 00-0000-0000
Fax: 00-0000-0000
E-mail: xxxxx@xxxxxx.co.jp
The applicant should fill out thisWhat material(s) do you want to reproduce or borrow?
form and submit it to the RIKEN
Description of the materials:
photograph of Dr. Xxxxxxx (high-quality image) Public Relations Office.
Types of materials (circle the appropriate item or items)(1) Printed material(2) Photograph (negative, positive, or electronic file)(3) Part of the RIKEN website
If the materials are expensive,(4) Display item(5) Microfilm(6) Other: __________________________
there may be some other
URL etc.: http://www.riken.jp/~xxxx/nishina.jpg
administrative procedures thathave to be followed.
Why do you want to use these materials? State the document or publication in which youplan to use them, the purpose, and the period for which you want to use them.
Title of document: A book we are publishing called Fifty Years of Hill Pharmaceuticals
Purpose of use: Include photo of Dr. Xxxxxxx and describe his great contributions to our research
Period of use: Publication is scheduled for January 2008 (see attached sheets for details)
Attach extra
sheets if
How do you want to use these materials? If your answer is (1), (2), or (3), circle “all” or necessary.
“part”.
(1) Reprinting (in an article or magazine or on a website) of all / part of the materials(2) Borrowing of all / part of the materials(3) Copying and distributing ____ copies of all / part of the materials(4) Other:

Conditions of use
Applicants (persons requesting permission to reproduce materials) must obey the following rules.
1. Take care not to damage or lose the materials.
2. If rights to the materials belong to a third party, get permission to use the materials from thethird party.
3. Use the materials only for the purpose described above, and do not lend or give the materials toany third party.
4. Use the materials only once, not repeatedly or continuously.
5. Specify clearly that the materials are provided by RIKEN, or specify the source clearly.
6. Provide to RIKEN one copy of the newspaper, magazine, book, or video recording of the TV
program, or one copy of the part where the materials are used and the part where RIKEN iscredited.
7. Do not trim photographs or write captions or explanatory text for them in such a way as toconvey a different meaning from the original photograph.
8. Return borrowed materials by the date on which they are due to be returned, or as soon as thework is finished. (Due date: 2007 / 2 / 20.)
9. Explain the contents of the publication in which the materials are used, if requested by RIKEN.
10. RIKEN takes no responsibility for any damage or loss that may result from the reproduction or
borrowing of its materials, to the party that uses the materials or to any third party.
11. The reproduction or borrowing of the materials must cause no damage or loss to RIKEN.
12. Issues not specified in this list shall be specified elsewhere.
13. Other:-------------------------------------------------------------------------------------------------------------------------If you areasking toborrowphotos orothermaterials
that need tobe returned,write thedate bywhich youwill returnthem, andtogether
with thisform also
submit theloanagreementform.

Date: 2007 / 1 / 11
To:

Boris Korey

You are permitted to borrow and reproduce the materials as described above.
A. Suzuki, RIKEN Public Relations Office
Hirosawa 2-1, Wako, Saitama 351-0198, JapanTel. 048-467-XXXX, fax 048-462-4715, e-mail koho@riken.jp

This part will befilled in by RIKEN,
and the form willthen be returned toyou.