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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

Your
Institution


Job Title Role in Institution
Department  
 
Institution
Institution Type
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
Purpose
Publisher
Editor
Author
Title
Language
Edition
Print Run (# of copies)
Number of Pages
Number of Illustrations
Image Placement
Image Type
Distribution
Estimated Price of Publication
Expected Date of Publication

Film Media
I will be using
this image in
Film Media
yes   no  
Type
Purpose
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
Purpose
Producer
Editor
Designer
Title or
Web Address
# of copies
Display Resolution
Term
(# of years)
Price
CD Format
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