Title of television program:

Studio/TV company:

Title of episode and/or number:

Time sequence of still within episode:

Description of scene 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:

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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