Form 190-3

Copyright Permission Form


Permission is requested to reproduce the following copyrighted material(s):

Title of work:






Format Modification/Translation

Language

Braille     Audiotape     Large Print

Excerpts or Adaptation (see attachment)
Other

Use of Materials 

Classroom Use (specify)

Special Circumstances (e.g., class newsletter, etc.)

Copyright Owner

Permission is hereby granted to  of   school to photocopy the material as specified above.

Credit Statement: 

Under the Following Conditions: 

Authorized by: 

Position: 

Company: 

Date: 

Adopted: May 18, 1989
Amended: May 9, 2006
Reference: Family Law Act - Section 20 & 21