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Series 407.6P - Request to Duplicate Copyrighted Material

Adopted: April 1978
Revised: April 2015

 

TO:       Date____________________   Firm_______________________________________

            Contact Person_________________________________________________________

            Title __________________________________________________________________

            Address________________________________________________________________

                        City                        State             Zip

            Telephone (       )                                        Fax (___ )                                     

            Email _________________________________________________________________

FROM: School(s)/Department(s)/District                                                                

            Address                                                                                                    

                        City                        State             Zip

            Telephone (       )                                        Fax (___ )                                     

            Email _________________________________________________________________

            Person making request                                                     Title                   

I/We are requesting authorization to duplicate/replay the following copyrighted material:

          Title                                                                                                            

          Author/Editor/Publisher/Creator                                                                 

Subject                                                                                                           

Medium                                                                                                      

Number of copies to be made:                           Copy medium:                                  

Use to be made of copies:                                                                                        

                                                                                                                            

Form of distribution (classroom, newsletter, etc.):                                                     

Copy(ies) to be sold:          No          Yes   Amount per copy                     

Anticipated date of first use:                                                                                   

Thank you for your cooperation.

PRODUCER/PUBLISHER REPLY

Permission          granted             denied

Details/Restrictions:                                                                                            

                                                                                                                            

Signature                                                                                                              

Title                                                                                       Date                        

Copy to:    •  Location(s) in building where copying occurs

                   •  Building file maintained by administration

                   •  Initiator

Procedures/407.6P/4-21-15