Management: Issues: Video Permission Form

 

Request for Permission for Classroom Use

Date:

Name of Copyright Holder:

Address of Copyright Holder:

Dear ___________________:

I am a _________________ teacher at _____________________ school. I request permission to reproduce and distribute the following material to students in my class(es).

Title of Work:

Edition or Copyright Date:

Author:

Portion of work to be used (specific pages, chapters, sections, illustrations):

Method of duplication (photocopier, scanner):

I will use the material for (supplemental information, example, review). I plan to use this material ___ times this academic year with about ____ students. The duplicated materials will be used only by my students in my classes at my nonprofit institution. Your copyright notice will be placed on all copies.

Please indicate your response in the space below and return the signed document in the enclosed envelope. Thank you for your consideration.

Sincerely,

Your Name, Title

Permission Notice

____ I grant permission to the above request.

–––– I do not grant permission to the above request. Consent granted:

–––– I grant permission to the above request with the following restrictions.

Signature of copyright holder

Name (please print): _______________________ Title:_________________________ Date:_____

 

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