Copyright Request Form

Course Title:

How often will the material be used? One time Every time the course is offered

What percentage % of the work will be used?

Location of desired material in the course:

If others, please specify:

Type of Material:

Requested Material:
Source:
Copyright Holder's Information:

Have you contacted the copyright holder for permission to use this material? Yes No

If yes, when?

What was the response from the publisher?

Was permission granted? Yes No

If Yes, specify limitation and/or expiration:

(If any)