Free REPRINTS AND PERMISSION REQUEST - Connecticut


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State: Connecticut
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http://www.jud2.ct.gov/webforms/forms/es209.pdf

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REPRINTS AND PERMISSION REQUEST
JD-ES-209 New 4-06

NOTE: All republished material must carry Judicial Branch credit. Unless specifically noted otherwise, all permission is given for one-time use only.

CONNECTICUT JUDICIAL BRANCH DIVISION OF EXTERNAL AFFAIRS 231 Capitol Avenue Hartford, CT 06106 www jud.ct.gov Telephone Number: (860) 757-2270 Fax Number: (860) 757-2215
DATE OF REQUEST TELEPHONE NUMBER FAX NUMBER

REQUESTOR IDENTIFICATION
NAME OF REQUESTOR (Last, first, middle initial) ORGANIZATION/AGENCY/DIVISION STREET ADDRESS CITY STATE ZIP EMAIL ADDRESS

REQUEST DESCRIPTION
1.) List the material that you are seeking to reprint:

2.) State the purpose and manner in which the material will be used:

3.) Describe the mission of the organization seeking permission:

4.) State whether the material requested will be used for commercial purposes and if so, in what manner:

5.) Will a profit be derived from the use of the copyrighted material?

6.) Will there be a charge for the product or program that includes the copyrighted material?

7.) If the requested material is to be placed in a publication, provide the name of the publication, and the context in which the material will appear:

8.) Estimated number of copies to be printed or produced. (If Intranet, number of users):

9.) Date(s) the material will be distributed:

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