University Archives Reproduction Request Form
Applicant Information
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
___________________________________________________________________________________
Phone: ________________________________ E-mail: ______________________________________
Description of the work in which the image(s) will appear
Title: _______________________________________________________________________________
Author/Editor/Presenter: ________________________________________________________________
Publisher: ___________________________________________________________________________
Expected Date of Publication/Presentation: _________________________________________________
Type of work (check one)
 Periodical
 Book
 Pamphlet
 Newspaper
 Television
 Lecture  Presentation  Personal use
 Film
 Videotape
 Other ______________________
Description of item(s) to be reproduced
Title: _______________________________________________________________________________
Author/Photographer/Publisher: __________________________________________________________
Date of creation/publication:_____________ Id number: ______________________________________
Photo CD/Sequence number: ____________________________________________________________
Format Requested
 Digital image
Platform ________________________File Type ____________ Resolution ________________
Required Citation
In addition to the title and Id number listed above, the following ownership credit must accompany the
reproduction either directly adjacent to the image or in that portion of the work where credits are given:
Thomas Jefferson University Archives and Special Collections, Scott Memorial Library,
Philadelphia, PA.
University Archives And Special Collections Department -Reproduction Request Form – Page 2
Description of item(s) to be reproduced
Title: _______________________________________________________________________________
Author/Photographer/Publisher: __________________________________________________________
Date of creation/publication:_____________ Id number: ______________________________________
Photo CD/Sequence number: ____________________________________________________________
Description of item(s) to be reproduced
Title: _______________________________________________________________________________
Author/Photographer/Publisher: __________________________________________________________
Date of creation/publication:_____________ Id number: ______________________________________
Photo CD/Sequence number: ____________________________________________________________
Description of item(s) to be reproduced
Title: _______________________________________________________________________________
Author/Photographer/Publisher: __________________________________________________________
Date of creation/publication:_____________ Id number: ______________________________________
Photo CD/Sequence number: ____________________________________________________________
Description of item(s) to be reproduced
Title: _______________________________________________________________________________
Author/Photographer/Publisher: __________________________________________________________
Date of creation/publication:_____________ Id number: ______________________________________
Photo CD/Sequence number: ____________________________________________________________
Description of item(s) to be reproduced
Title: _______________________________________________________________________________
Author/Photographer/Publisher: __________________________________________________________
Date of creation/publication:_____________ Id number: ______________________________________
Photo CD/Sequence number: ____________________________________________________________
Description of item(s) to be reproduced
Title: _______________________________________________________________________________
Author/Photographer/Publisher: __________________________________________________________
Date of creation/publication:_____________ Id number: ______________________________________
Photo CD/Sequence number: ____________________________________________________________