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Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

When was the photograph/video taken? Date and time.*

Where was the photograph/video taken? Be as specific as possible and include street names, identifying markers, or coordinates.*

What is the photograph/video of?*

Tell us the story behind the photograph/video. Why did you take this? What can it tell us about life during the pandemic?*

Please list the full names of the people in the photograph/video and their relation to you.*

Additional comments, memories, recollections, etc?

File

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