Title of strip/illustration:

Illustrator(s) [please include first and last name(s)]:

Syndicate:

Date:

If material is taken from a web site, state the complete web site name and address:

I am asking for (select one):
photocopy rights      electronic rights

If used at web site, state URL:

If used at web site, is the site password protected?  Yes      No

If you would like a copy of this form enter e-mail address: