Department for Culture, Media and Sport 
Government Art Collection 
Old Admiralty Building, Admiralty Place, 
London, SW1A 2BL 
Email: gac@dcms.gov.uk 

REPRODUCTION APPLICATION FORM (Form RA)

Permission is requested to film or reproduce an image of the following work(s) of art in the Government Art Collection

Works of art required (delete or add rows as required)
Artist: type answer here
Title: type answer here
GAC Inventory Number: type answer here
Colour or Black & White: type answer here

Artist: type answer here
Title: type answer here
GAC Inventory Number: type answer here
Colour or Black & White: type answer here

Artist: type answer here
Title: type answer here
GAC Inventory Number: type answer here
Colour or Black & White: type answer here

Purpose for which the image is required e.g. book, website, TV program: type answer here

Language Rights requirements (delete rights not required) * EC counts as one country

Book/Magazine (First use only) 
One Language: One Country * 
World Rights: One Language
World Rights: Multilingual

Cover and/or inside use: type answer here

TV/Film/Cable/Video
One showing/broadcast/transmission in one language in one country *
World Rights: unrestricted number of showings/transmissions/broadcasts in any language/country, over a 10 year period, commencing from the date reproduction permission is granted.

Other (please specify): type answer here

Languages and/or countries in which media form will be shown/distributed/broadcast/transmitted: type answer here

Proposed Title: type answer here

Brief description of content: type answer here

If Media Form is Television/Film/Video (delete section as appropriate)
Name of television channel broadcasting or distributing the film/TV programme or the service/person through which transmission or broadcasting will be effected: type answer here
Name of Director and producer: type answer here
Number of copies to be made: type answer here
Date of release/showing: type answer here

If Media Form is a printed publication (delete section as appropriate)
Name of author: type answer here
Estimated print run: type answer here
Approximate date of publication (and edition, if applicable): type answer here
Name and address of publisher: type answer here

If Media Form is a website (delete section as appropriate)
Web address: type answer here
Home Page or Supplementary Page: type answer here
Duration of use (delete as appropriate)
Period of exhibition only 
One year 
Up to three years 
Over three years

Your Details
Name and address of applicant: type answer here 
Telephone No: type answer here
Email address: type answer here