First name * Prénom *

Last name * Nom de famille *

Home Address Adresse domiciliaire

Email * Email *

Type of material

Type de document

Will you send this material through email or the internet? Pensez-vous envoyer ce document par mail ou internet? Yes No

Will you send this material through postal services (costs paid by us)? Pensez-vous envoyer ce document par la poste? Yes No

Which terms would best describe this material? * Quel(s) terme(s) décri(ven)t le mieux ce document? * Example: Article, Artwork, Banner, Blog, Book, Cartoon, Comment, Debate, Drawing, Ephemeral, Essay, Fiction, Film, Graffiti, Magazine, Manuscript, Newspaper, Object, Pamphlet, Photograph, Poem, Poster, Song, Text, TV program, Tweet, Website, etc. Exemple: Affiche, Article, Bannière, Blog, Caricature, Chanson, Commentaire, Débat, Dessin, Émission de télévision, Éphémère, Essai, Fiction, Film, Graffiti, Journal, Magazine, Manuscrit, Livre, Objet, Œuvre d’art, Pamphlet, Photographie, Poème, Site web, Texte, Tweet, etc

Describe in your own words the material you would like to donate * Décrivez en vos propres mots le document que vous voudriez donner * Maximum 100 words. Maximum 100 words.

Location of the material Emplacement du document Where the material was made, found, used, processed, etc. où il a été fait, trouvé, utilisé ou traité

Date of the material Date du document When the material was made, found, used, processed, etc. quand il a été fait, trouvé, utilisé ou traité



Author, maker, source Auteur, fabricant, source

Please attach a photo of the material, if possible Veuillez joindre une photo du document, si possible Accepted image formats include jpg, png, and tiff. File size must not exceed 1 MB. Accepted image formats include jpg, png, and tiff. File size must not exceed 1 MB.

Would you like your name included in the Archive? Est-ce que vous voulez inclure votre nom dans les archives? Yes No

If my proposal is accepted, I agree to donate this material to the Charlie Archive at Harvard University Library for preservation and distribution for research and educational purposes. I understand that I will not receive financial compensation. * Si ma contribution est acceptée, je m’engage à donner ce document aux archives Charlie de la Harvard University Library, où il sera préservé et distribué à des fins pédagogiques et des fins de recherche. *

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