Rights and Reproductions Request

Organization *

Organization Type

Name *

First

Last

Title

Address

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone *

Cell Phone

Business Fax

Email *

Organization Website / URL

Type of Material *

Requested Material Details *

Object Number (If Known)

Additional Information (frame or image number, time code, etc.)

Type of Use Intended *

Purpose of Use *

Context of Intended Use

Primary Format/Media of Use *

Additional Formats/Media Rights

Projected Date of Publication, Broadcast, or Distribution *

Title

Author, Editor, or Producer

Geographical Distribution

Language(s)

Print Run/Circulation

Number of Broadcasts

License Term

Additional Details/Explanation