Is the selection an original visual image? Yes No
Title of work of art:
Artist:
Is the selection a reproduction (e.g. 35 mm slide, color transparency, print)?: Yes No
State the type:
Is this selection from a published reproduction, such as a book or web site?: Yes No
Title of book:
Editor(s) [please include first and last name(s)]:
Publisher:
Complete web site name and address:
Is the selection from a copy of a published reproduction?: Yes No
Type of copy (e.g. 35 mm slide, color transparency)
Title of project:
Purpose of project:
Intended use of image in project:
Number of copies of project:
Are copies to be distributed or retained by instructor?:
If distributed, what is the mode of distribution?:
Mode of instruction:
Length of time the contract needs to cover:
If you would like a copy of this form enter e-mail address: