Image Use Request Form

Organization Name
Contact Name *
Phone Number *

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Email *
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Image(s) requested *
First-time use or re-use: *
 First-time use 
 Re-use 
For-profit or non-profit *
 For-profit 
 Non-profit 
Intended use (check all that apply) *
 Article/Journal 
 Book 
 E-book 
 Exhibition 
 Book cover 
 DVD 
 Broadcast program 
 Website 
 Research only 
 Mural in public space 
 Other  
Title of publication/exhibition: *
Please write "n/a" if your project does not have a title
Author and publisher (if applicable)
Press run (if applicable)
# of copies
Film/Broadcast use (if applicable)
 DVD for commercial resale 
 Television broadcast 
Internet/Website use (if applicable)
 Less than one month 
 Less than six months 
 Six months or more 
Expected Publish/Release Date:

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Preferred method of image delivery *
 Electronic 
 CD-R 
 DVD-R 
 Print 
Additional information
Image Verification
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