Name
First
Last
Title
Company Name
Address
Address Line 1
Address Line 2
City
Zip Code
Country
Phone
Job #
Total # of photos requested
Photo ID #’s
Photo descriptions
Usage type
Advertising
Corporate
Editorial
Nonprofit
End User’s Name (your client)
End Product
Annual Report
Brochure
Magazine
Newsletter
Sales Aid
TextbookBook
Billboard
Poster
Packaging
TV
Other
Publication (or presentation) Title
ISBN #
Date
Press Run or Circulation
Publication size in inches
Image Size relative to page
¼
½
¾
Full page
Double Page
Various
Video
Placement
Inside
Chapter Opener
Cover
Inside Cover
Back Cover
Other
Distribution
National
Regional
Local
In-house
Other
Electronic Rights
None
Yes
Exclusivity
Non-exclusivity
Exclusivity
Other
Period of License
One Time
3 Months6 Months
12 Months
Other
Usage Period Starts
Usage Period Ends
How many times will Ad repeat?
Explain
Usage Rights Area
North American English Language only
International
Other
Will client provide photo credit?
yes
No
Comment or Question