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Instructor:
Course #:
Is the selection an original visual image?: Yes No
Title of work of art:
Artists(s) [please include first and last name(s)]:
Is the selection a reproduction (e.g. 35 mm slide, color transparency, print?: Yes No
State the type:
Is the selection a published reproduction such as a book or a website?: Yes No
Title of book (if applicable):
Editor(s) [please include first and last name(s)]:
Publisher:
Complete website name and address (if applicable):
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