The Champlain Society

Use Permission Form

Permission for Use

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

Any fields marked with an asterisk (*) are required

Requester Information

First Name		*	A value is required.A value is required.
Last Name		*	A value is required.A value is required.
Position/Title
Name of Organization
Address		*	A value is required.
City		*	A value is required.A value is required.
Province / State		*	(Where applicable)
Postal / ZIP Code
Country		*
Website Address / URL
Phone #			A value is required.
Fax #
E-Mail Address		*	A value is required.Invalid format.
Have you previously received permission to reproduce the requested material? Yes No
Source Material Information
	Title:	*	Please select a valid item. Please select a valid item.
	Page #'s To Be Used	*	A value is required.Minimum number of characters not met.A value is required.
Intended Use:
Number of Copies To Be Reproduced		*	A value is required.Minimum number of characters not met.A value is required.
If Other Than Print?			Use in Media, not print
Nature of Intended Use (Check all that apply)
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 and/or are non-profit organization created by law?) Educational (i.e. Are you a university; college; pre-school, elementary, secondary school)
If Commercial
	Proposed Retail Price	$
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.

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

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The Champlain Society

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