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Agreement to permit duplication and Use of copyrighted works
________________ , a corporation/individual located at ________________ , as the copyright holder, or with the authority to act on behalf of the copyright holder, hereby grants North Carolina State University, for its ________________ department, located at ________________ , permission to duplicate and use the following material according to the following terms:
Title: ____________________________________________________
Copyright holder: __________________________________________
Author/Editor: _____________________________________________
Page #s/frame #s: __________ Year of Copyright: ___________
Periodical: ________________________________________________
Date of Periodical: ________ Volume: __________
Color and style: ____________________________________________
Print size: _________________________________________________
Period of intended use: _______________________________________
Date of first use: ____________________________________________
Material is to be sold: ________________________________________
To cover costs: ________ To exceed costs: ________
Payment due (if any) ________________________________________
Method of Reproduction:
_____ negative microfilm
_____ photocopy
_____ positive microfilm
_____ binding
_____ photo prints
_____ reader/printer
_____ ditto
_____ typeset
_____ offset
_____ (other)
Types of material to be reproduced:
_____ Audiovisual works (including motion pictures)
_____ Dramatic works
_____ Script
_____ Script with accompanying music
_____ Literary works
_____ Musical works (includes words)
_____ Pantomime and choreographic
_____ Pictorial or graphic
_____ Sound recording
_____ Scholarly work
Use to be made of duplicated materials:
_____ Research
_____ Teaching
_____ For distribution
_____ Not for distribution
Visual art works
For works of visual arts, 17 United States Code 106A provides the artist with certain rights of attribution and integrity independent of copyright. The artist who created the work(s) described above hereby exercises those rights as follows:
1.[ Insert any provisions related to attribution or other recognition of the artist ]
2.[ Insert any provisions related to modification of the work if modification is required for the use described above. E.g., artist may want to review and approve of a poster or shirt on which her artwork is printed, or artist may feel the description of the use above is sufficiently detailed to allow her to approve of that specific modification, if it is a modification, without further review. ]
Agreed to By:
Copyright Owner signature: _____________________________________ Date: _________
Printed Name: ________________________________
Artist signature (if different from copyright owner): _____________________________________ Date: _________
Artist printed name: ________________________________________