AMICO Reproduction Request Form

Please fill out as much of the following form as possible:

Work Requested:

Mummy Case of Paankhenamun. Third Intermediate Period, Dynasty 22, c. 945 - 71 Egyptian. The Art Institute of Chicago. No. 1910.238. Photo: Copyright The Art Institute of Chicago, 1998.

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

General Information:

Quantity of Reproduction Deadline (Date Reproduction Needed By) 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 for image reproductions.

Intended Use and Relevant Information:

Check here if request is for study purposes only

Print Media

I will be 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 Educational Nonprofit Publisher Editor Author Title 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 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 Educational Nonprofit Publisher Editor Producer Title Audience Run Period Distribution/ Syndication Estimated Price of Product Expected Date of Release

Digital Media

I will be using this image in Digital Media yes   no   Type Select One CD-ROM Software Website Other Purpose Select One Commercial Educational Nonprofit Publisher Editor Designer Title or Web Address Edition Print Run (# of copies) Term (# of years) Display Resolution CD Format Select One Hybrid Mac PC Estimated Price of CD/Software Distribution Expected Date of Release

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