5:170-E1 – Request to Reprint or Adapt Material
On District letterhead
On behalf of the School District, I am requesting permission to reprint [to use without change] or adapt [to use and modify] the following material:
No reprinted or adapted material will be used in a sales promotion or advertising campaign. If permission to reprint or adapt this material is granted, the material will be used for the following purpose(s):_____________________________________
The following credit line will appear on each reprint or adaption:
|Reprinted/Adapted, with permission from (publication) _________________Copyright year of publication _____________________Copyright owner _____________________All rights reserved.|
If you agree to grant permission for the School District to reprint or adapt the above listed material, please sign the Permission to Reprint or Adapt Material and return it to the requestor.
Please contact me at ____________________ if you have any questions. Thank you for your consideration.
School District Requestor (please print) Email/Fax
Permission to Reprint or Adapt Material
I hereby grant permission to the School District requestor to reprint or adapt material as requested on the terms and conditions stated herein.
Copyright owner (please print)
Date Approved: October 12, 2011