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:
PRINT
RESET