Copyright and Reprint Permission Request Form

Before filling out this form, please carefully read our Copyright and Terms of Use page to see if you need to submit a copyright permission request. For many of our materials, including fact sheets, brochures, toolkits, and wellness modules, if you follow the Terms of Use guidelines, you do not need to seek permission for private use.

This form is required:

If you diverge from the guidelines, such as seeking permission to change a work, charge for a work, or distribute the work to an audience.
If you are seeking permission related to Visions Journal and its articles, or any Personal Stories. (All articles from Visions are appended with a note saying they are from Visions, including issue and page numbers.)

Requester information

Name of requester

Title

Name of organization

Mailing address

City

Province / State

Postal/Zip code

Country

Organization web site address

Phone number

Please include country code if you are outside North America

Fax number

Please include country code if you are outside North America

Email address

Publication Information

Exact title of the publication you are seeking permission to reprint

If you have several publications, and the request is the same for each, please separate the titles with semicolons. If each intended use is different, please fill out a separate form for each resource.

Date of the publication you are interested in reproducing

There are sometimes different versions of our materials, particularly in print circulation. The date will help us know which version you are interested in.

Intended Use

How much of the publication are you interested in reproducing?

If you answered "part," please list page numbers or describe which part

Format of requested reproduction

Online

Other

If print, the number of copies to be reproduced

Have you previously received permission from us to reproduce material in a similar way?

What is the approximate period of time you will be distributing the material?

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 a non-profit organization created by law?)

(check all that apply)

If commercial, please specify proposed retail price

Please provide any additional details such as purpose or other contact information

Copyright and Reprint Permission Request Form

Requester information

Publication Information

Intended Use

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