AMICO Reproduction Request Form - SAMPLE This is an example of the AMICO Reproduction Request form. To submit a request, first query for a work in the Thumbnail Catalog. Work Requested Hunter with Walrus Head. 1955-1960 Attributed to Aisa Qupirualu Alasua. Art Gallery of Ontario. No. 96/572. Copyright 1998: Art Gallery of Ontario. Photo: Copyright 1998, Art Gallery of Ontario. Requester Information Your Name Prefix First Name Middle Initial Last Name Dr. Mr. Mrs. Ms. Your Institution Job Title Role in Institution Choose One College / University Faculty College / University Staff Primary /Secondary School Teacher Librarian Museum Curator Museum Staff Graduate Student Undergraduate Student K-12 Student Life-Long Learner Other Department Institution Institution Type Choose One College / University Primary /Secondary School School Board Public Library Consortium Museum / Collecting Institution Distributor Other Your Address Street Suite / Building City State / Province Postal Code Country Office Phone Ext. Office Fax Web site Email *Fields with orange names are required Reproduction Requested Project Name Deadline Medium 35 mm slide Color transparency Black and white photograph Digital file Black and white print Negative Color print Other (specify) Note: Some Institutions may only offer one type of media. Quantity Intended Use Check here if request is for study purposes only Print Media I will be using this image in Print Media yes no Type Select One Advertising Book Brochure Calendar Exhibition Exhibition Catalog Journal Magazine Poster Product Packaging Other Purpose Select One Commercial Nonprofit Publisher Editor Author Title Language Edition Print Run (# of copies) Number of Pages Number of Illustrations Image Placement Select One Cover Illustration Full Page Half Page or Less Inside Cover Other Image Type Select One Color Black & White Distribution Estimated Price of Publication Expected Date of Publication Film Media I will be using this image in Film Media yes no Type Select One A-V Presentation Film Television Video Purpose Select One Commercial Nonprofit Producer Director Title Audience Term Restrictions Territory / Language Price Release Date Digital Media I will be using this image in Digital Media yes no Type Select One CD-ROM Website Other Purpose Select One Commercial Nonprofit Producer Editor Designer Title or Web Address # of copies Display Resolution Term (# of years) Price CD Format Select One Hybrid Mac PC Distribution Release Date Submit Your request will be forwarded to the appropriate AMICO Member, and if necessary also copied to the rights holder's representative. You will receive an email copy of your request. A response will come directly from the AMICO Member or Rights Society. Some charges and further agreement to terms may be required. Return to the Main Reproduction Request Form Page
Check here if request is for study purposes only
Your request will be forwarded to the appropriate AMICO Member, and if necessary also copied to the rights holder's representative. You will receive an email copy of your request. A response will come directly from the AMICO Member or Rights Society.
Some charges and further agreement to terms may be required.
Return to the Main Reproduction Request Form Page
