Title of video/film:

Studio/Movie company:

Time sequence of clip within film:

Description of scene in in still (or attach copy of still):

Intended use of still in the project:

Title of project:

Purpose of project:

Synopsis of project:

Accompanying text or caption:

Number of copies of project:

Will copies be distributed or retained by instructor?:

If distributed, what is the mode of distribution?:

Countries of distribution:

Mode of instruction:

Length of time the contract needs to cover:

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