Permission to Use Copyrighted Material Short form



FOR GOOD CONSIDERATION, the undersigned, as copyright holder, hereby grants permission to ____________, to reprint, publish and use for world distribution the following material: (Describe or attach)

This material shall be used only in the following manner or publication: (Define intended use)

A credit line to acknowledge use of the material is _____ is not _____ (check one) required. If required, the credit line shall read as follows:

Dated:

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