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SynCardia Systems, Inc.

Multimedia Image Request Form

To request SynCardia images or video for use in an article or presentation, please fill out the form below. The more information you provide, the faster we will be able to fulfill your request.

Requested Information

    An (*) indicates required fields

    1. Requestor's Full Name(*)
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    2. Job Title
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    3. Company/Affiliation
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    4. Email Address(*)
      You must supply a valid email address
    5. Phone Number
      You must supply a phone number
    6. Street Address
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    7. City
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    8. State
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    9. Zip Code
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    10. Country(*)
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    11. For Image Requests:
    12. Date image needed by:
      Please supply the Date Images needed by
    13. Requested Image(s), Animation, Audio Information: View Images Here
    14. Image #1 description or URL:
      You must supply at least one requested image
    15. Image #2 description or URL:
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    16. Image #3 description or URL:
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    17. Image #4 description or URL:
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    18. Image #5 description or URL:
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    19. Image #6 description or URL:
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    20. Additional Image Information Request
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    21. Description of Purpose:
    22. Title of work in which images(s) will appear:
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    23. Publication name:
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    24. Expected publication date:
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    25. Context in which the image will be used (check all that apply):

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    26. Other
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    27. Website URL:
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    28. Please enter the text in the image
      Please enter the text in the image
      RefreshThe text entered does not match. Please try again
    29. Requirements for Permission to Use SynCardia Images - applies to media and other published requests
      1. • The following credit line must accompany each image: “Courtesy:”
      2. • Copy of the material to be provided to SynCardia within three days of publication.
      3. • SynCardia may post the content or information regarding the content on
    30. Digital Signature*
    31. You MUST select the Check Box below and then type your FULL NAME in the box provided before hitting the submit button. If you fail to do so, please hit the back button and select the link to the form again.
    32. By checking here and clicking "submit" below, I, , (please enter your full legal name) verify that the information I have submitted is true and accurate. (Note: Once you supply the following information and click submit, you will be digitally signing this form. You will not be able to edit this form. A copy will be emailed to you for your records.

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