Photo Gallery Submission Form

You must complete ALL fields in the submission form.
Contact information will be used solely for contacting photographers for permission to use photos elsewhere.

Photographer Information

Name:
Address:
City:
County:
State:
Zip:

E-mail:
Telephone:

Photo Information

Date Photo Taken:
Location of Photo:
Title of Photo:
Description of Photo (50 words or less):

Category: ____ Nature   ____ Community  ____ Wildlife

Agreement Statement
I certify that (1) I have read and agree to the Kansas.gov Photo Gallery Submission Guidelines; (2) I am properly submitting this photo and complying in all respects with the Photo Gallery Guidelines; I represent and warrant that (1) I own all rights, title and interest in and to the photo attached to this entry form ("Photo"), (2) the Photo is my original work, (3) the Photo does not infringe the intellectual property or other rights of any other person or entity, and (4) I have all of the necessary rights and authority to submit the Photo. I understand that by submitting this Photo, I am granting to Kansas.gov a limited license to publish and display the photo, along with my name and information about the photo, on the Kansas.gov Web site and Kansas government Web sites, without further compensation, and to make copies of the photo for archival purposes. I understand that submitted photos will not be returned. I, on behalf of myself, my heirs and assigns, hereby release, indemnify and hold harmless Kansas.gov and its employees, officers, affiliates, agents, and advertising and promotion agencies from any and all damages, injuries, claims, causes of action or losses of any kind resulting from my Photo including infringement of intellectual property rights.

____ I AGREE       ____ I DISAGREE

Contact Information Release Statement
I give Kansas.gov permission to release my contact information (name, phone number and e-mail address) to companies that request in writing (mail, e-mail or fax) to discuss with me the use of my photo for commercial purposes i.e., advertising or publication. Contact information will not be released for any other purpose. It is my sole discretion to permit use of my photograph for any purpose other than the Kansas.gov Web site and Kansas government Web sites..

Note: Photographers are not required to agree to this statement to have their image displayed on the Kansas.gov Web site and/or Kansas government Web sites.

____ I AGREE       ____ I DISAGREE

Signature:
(type if submitting form electronically)