Image Reproduction Form

* Indicates a required field

Date:

Application for Permission to Reproduce Photographic Materials of Works of Art from the Collections of the University Museums, Iowa State University, Ames, Iowa.

Permission is hereby requested by:

Name / Company Name:

Address:

Phone:

xxx-xxx-xxxx

Email:

to reproduce photographs of the following object(s) [please provide tile/artist and additional object information if known]:

in:

Color

Black and White

For editorial use in:

Title of publication or website:

author, editor, or website manager:

name and physical address of publication, also include web address for digital media:

For other use

Describe: