1. Your Name and Contact Details (Please Print)

INTERVIEWEE

1. Your name and contact details (please print)

Title:______

Given name: ______

Family name: ______

Honours: ______

Address: ______

______

Phone:______

Mobile: ______

E-mail:______

2. Which of your contact details may we give to enquirers?

□ None: I would prefer the Museum of Australian Democracyto contact me on the enquirer’s behalf

□Address

□Phone

□Mobile

□E-mail

3. Your biographical details

Date of birth______

Profession/occupation______

Brief biography (or attach separately)

______

______

______

______

______

______

______

______

______

______(or attach separate biography)

4. Name of additional contact (Optional)

Title:______

Given name: ______

Family name: ______

Address: ______

______

______

Phone:______

Mobile: ______

E-mail:______

MATERIAL COVERED BY THIS RIGHTS AGREEMENT

Material includes the audio recording made from this interview, any transcript text created as a result of the interview, other related material provided by the interviewee and any photographs taken during the interview session.

Interviewee name:______

Interviewer name:______

Place of interview:______

Date of interview:______

5. May the Museum of Australian Democracypermit unrestricted access to and use of the Material?

The Museum of Australian Democracy usually allows members of the public to

• access material (= view it or makes notes about it or listen to it), and to
• use material (= copy it or publish it or use it in public ways)

□ Yes > Go to 10

□ No > Go to next question

6. May allow people to access and make notes about the Material on the Museum of Australian Democracy’s premises?

(a) □ Yes

(b) □Yes, but only if the Museum of Australian Democracy has received my specific permission on each occasion

(c) □Yes, but only after the following date or event

______

(e.g. ‘2015’ or ‘after my death’)

7. May the Museum of Australian Democracy allow people tohave copies of the Material for personal use?

(a) □Yes

(b)□Yes, but only if the Museum of Australian Democracy hasreceived my specific permission on each occasion

(c) □Yes, but only after the following date or event

______

(e.g. ‘2015’ or ‘after my death’)

8. May the Museum of Australian Democracymake the Material accessible through its website, provided that the Museum of Australian Democracyrequires the end user to agree to the online End User Licence conditions which limits uses and defines responsibilities?

(a)□Yes

(b) □Yes, but only after the following date or event

______

(e.g. ‘2015’ or ‘after my death’)

Date or event must not be later than date/event in question 9.

9. May the Museum of Australian Democracy provide copies of the Material for use in performances, transmissions, broadcasts, publications, films and in other public ways, including uses in online media?

(a)□Yes

(b) □ Yes, but only if the Museum of Australian Democracy has received my specific permission on each occasion

(c) □Yes, but only after the following date or event

______

(e.g. ‘2015’ or ‘after my death’)

10. Agreement

I note and agree that

• the Commonwealth owns copyright in this recording and any associated transcript or summary
• the Museum of Australian Democracy will only provide access to it in accordance with the provisions I have specified in this document or any subsequent changes made by me.

11. Interviewee’s signature

______

(Signature)(Date)

12. What to do with this form

Please give the completed form to your interviewer or return it by post to:

Oral History Program

Research and Collection Development

Museum of Australian Democracy at Old Parliament House

18 King George Terrace

Parkes, ACT, 2600.

For inquiries please contact Museum of Australian Democracy at Old Parliament House on tel. + 61 2 6270 8222 or email