Permissions Form

This form is required for us to review of your permission application. We are not able to review an incomplete application.

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Name: *
Job Title:
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Home Phone:
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Permission Requested for the Following Copyrighted Materials:
Publication Title: *	Examples: STEP, BASC, PPVT, SSRS, etc.
Component Title: *	Examples: The Parent Handbook, PRS-P Form, Performance Record Form IIIA, Student Form-Secondary Level, etc.
Author(s):
Copyright Year: *	Without this information, your application will not be processed.
Page Numbers:	(Provide specific Pearson Assessment page numbers - not your numbers.)
Test Item Numbers:	(Provide specific Pearson Assessment test item numbers - not your numbers.)
Title of your Research or Book:	Example: Vocabulary: Receptive Indicators in Preschool Language Development
Reason for Request: *	Example: Request permission to copy pages 1-4 to use as a handout in a parenting class.
Explanation of Use: *	Handout Research School/Local Cable Access Only In Published Materials Back-Up copy Publication Out of Print Braille/Large Print Presentation Advertisement Other
Total number of copies: *
Used on the basis of:	One time only Per year (ongoing) Examples: One time only = one time presentation handout Per year = copies for quarterly meeting or annual workshop
Copy Medium: *	What method will you use to duplicate the material? Photocopy Computer Disk/CD Audio Video Transparency Other
If you wish to send an attachment in support of this request, do so in a separate email.
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