Copyright Permission Services - Course Pack Order Form

About Instructor

Name (as it will appear on coursepak): (Required)

(ex. John Scott, Ph.D.)

E-Mail Address: (Required)

Phone: (Required)

Campus address:

Campus phone:

About the Course

Full course name: (Required)

Course and section number: (Required)

(ex. HUM 860-01)

Instructor: (Required)

Expected enrollment: (Required)

Copying Specifications

Specifications

Color section dividers

Printed single-sided

Printed double-sided

Bound: Spiral

Bound: Staple

Bound: 3-hole punch

Bound: Shrink wrap

Special instructions

Copyright and Fair Use

Does this contain copyrighted work? (Required)

Yes
No

Do you have permission from all copyright holders to make multiple reproductions?

Yes (Written permission must be shown.)
No (Complete the Permission Request Form.)

This request conforms to Fair Use guidelines:

Must complete Fair Use Checklist for file.

Yes
No

If request is Fair Use, has the material been used before?

Yes
No

If yes, indicate number of uses:

Additional Information

Is this request for Digital Delivery of material?

Yes
No

Is this request for Distance Education?

Yes
No