Title of Work:____________________________________________________________

Author:_________________________________________________________________

Format (Book, periodical, DVD, etc.):_________________________________________

Publisher:_______________________________________________________________

Request initiated by:_______________________________________________________

Address:________________________________________________________________

Telephone:_______________________

Email:______________________________

Do you represent (check one):

_____ Yourself _____ An Organization (name)________________________________________

_____ Other Group (name)_______________________________________________________

1.Have you read or viewed the entire work?______________

If not, which parts did you read or view? ______________________________________________________________________________________________________

2. To what in the work do you object?________________________________________________________________________________________________________

3. What do you feel might be the result of reading or viewing this work?______________________________________________________________________________________

4. What do you believe to be the theme of this work?_____________________________________________________________________________________________________

5. Are you aware of any reviews of this work by critics?___________________________

6. In its place, what work would you recommend that would convey as valuable a picture and perspective of the subject area treated?_______________________________________________________________________________________________________

Your Signature_______________________________________

Date___________________________