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Permission Request Form

* Required information

What material are you requesting permission to reprint?

* Title
* Author
Type of material

(please specify Other)
List the page numbers or video segments you wish to use
* Number of people who will read or view the duplicated material

How will this material be used?

* Where do you wish to reproduce the material?

(please specify Other)
Please provide specific information about how the material will be used. If applicable, provide the web address (URL) where the material will be reproduced.

Please provide your contact information so that we can send you a response.

* Full Name
* Title
* Organization
City, State, Zip
* E-mail address

If we approve your request, we will send you a form to sign and return to us. How would you like to receive this form?

* Format:

Note: Because your signature and the signature of an Active Parenting staff member is required to complete this process, we must send you a form to sign and return. (If you choose the e-mail option, you will need to print, sign, scan, and re-send the form

What is your deadline for receiving a response?
Is there any additional information we should know?