| SIGNATURE: | ____________________ | DATE: | _______________ |
| |
| Application for permission to copy in the galleries is made by: |
| Name: | __________________________________________________ |
| Address: | __________________________________________________ |
| City and State: | __________________________________________________ |
| Telephone: | __________________________________________________ |
| School Affiliation: | __________________________________________________ |
| |
| Artwork for which permission to copy is being requested: |
| Artist: | __________________________________________________ |
| Title: | __________________________________________________ |
| Accession number: | __________________________________________________ |
| Gallery: | __________________________________________________ |
| Days that copying will occur: | __________________________________________________ |
| Registrar's Approval: | __________________________________________________ |
| Dimensions of work to be copied (to be filled in by registrar): | __________________________________________________ |
| Protection Services Approval: | __________________________________________________ |