5:170-E1 – Request to Reprint or Adapt Material

On District letterhead

Date:  _____________________

To:     ______________________________

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

___________________________________                     ___________________


Signature                                                                           Date



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)

___________________________________                 ______________________


Signature                                                                      Date


Date Approved: October 12, 2011