Copyright Permission Request Form

To receive permission to reproduce all or part of a BCER publication on our website, please complete the following form. To help us process your request in a timely manner, please be sure that the information you provide is both accurate and complete.

Please Note: the majority of copyright requests will be subject to a processing fee.

Requestor Information

Name

Title

Name of Organization

Phone

Fax

Address

Have you previously received permission to reproduce the requested material?

Yes

Source Material Information

Source Title

Website URL

Date of Publication

Total Number of Pages in Publication

Page numbers to be reproduced

Intended Use

Number of Copies to be Reproduced

Details

Please provide all relevant details, including the purpose served by the proposed work, and contact information for other persons or parties involved in the production or distribution of the proposed work.

Nature of Intended Use

Commercial (i.e. Are you profiting from distribution of the material?)

Non-Commercial (i.e. Will you be giving the material away free of charge?)

Educational (i.e. Are you a university; college; pre-school, elementary, secondary school; or non-profit organization created by law?)

Other

(Check all that apply)