| *Required
Information 1. What
material are you requesting permission to reprint?
*Title:
*Author:
ISBN:
Copyright year:
If you wish to duplicate a book:
Page
range: :
Total # of pages: :
If
you wish to duplicate a video:
Description
of video segment(s):
Total length of video segment(s):
2.
*Number of
people who will read or view the duplicated material?
3.
*How will
this material be used?
In
a textbook or journal article (go to question 4a)
On
a web site (go to question 4b)
Other
(go to question 4c)
4a. If the material will be reprinted in a textbook
or journal article:
Title of book or journal:
Author/editor:
Publication date:
4b.
If the material will be reprinted on a web site:
Name of Company/Organization with
web site:
Web Address (URL):
Commercial Nonprofit
4c.
If you selected “other” above, please
provide a description of how the material will be
used:
5.
Please provide us with your contact information so
that we can send you a response.
*Name:
*Title:
*Organization:
*Email:
(Please note:
Your e-mail address will be used only for purposes
related to your request. Active Parenting does not
share or sell e-mail addresses.)
If we
approve your request, we will send you a form to sign
and return to us. How would you prefer that we send
the form?
Fax
Postal Service (Please note:
Because your signature and the signature of an Active
Parenting staff member is required to complete this
process, we must send you a return form by either fax
or postal service. We will require you to sign the
form and return it to us by fax or post, as well.)
Address:
City:
State: Zip
code:
Country:
Phone:
Fax:
6.
What is your deadline for receiving a response?
7.
Any additional information we should know?
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