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Copyright Permission Form

Copyrighted Materials Agreement

The Ohio State University Extension

The Ohio State University, on behalf of its Cooperative Extension Service, grants the requestor indicated below (“Requestor”) permission to utilize the copyrighted image(s)/material(s) attached hereto as Exhibit A in the manner described below:

 

Description of Image(s)/Material(s):_________________________________________________________

Image(s)/Material(s) Type:________________________________________________________________

Author(s)/Editor(s) (if known): ____________________________________________________________

Payment due (if any):____________________________________________________________________

 

Requestor’s use of the image(s)/material(s) will be limited to:

 __ Reproduction

 __ Photocopies

 __ Photo prints

 __ Distribution

 __ Other:_________________________________

 

For the following purpose(s):

 __ Teaching

 __ Research

 __ Publication

Please specify:

Publication: ______________________________________

Title: ___________________________________________

Author(s):_______________________________________

Date(s) of Publication:                                                                       

__ Personal use

__ Other:________________________________________

 

Please provide a description of intended use, including the intended date of first use.

For publication please provide a description of the image(s)/material(s) and location of image(s)/material(s) in the publication including page number and caption:

______________________________________________________________________________

______________________________________________________________________________

In each of the above cases appropriate citation/attribution regarding the source of the image(s)/material(s) must be given (e.g., “Used with permission of The Ohio State University Extension, 2120 Fyffe Road, Columbus, OH, 43210.”)

This agreement is valid for a period of 2 years from the date of the last signature below. To extend this agreement a new agreement must be signed by both parties.

 Except for the permission(s) specifically granted herein, The Ohio State University retains all other rights, title and interest in the copyrighted image(s)/material(s).  All permission(s) herein granted shall be non-exclusive.

This agreement shall be construed and enforced in accordance with the laws of the United States of America and the State of Ohio.  This agreement constitutes the entire agreement between the parties regarding the subject matter hereof and supersedes any and all prior negotiations, agreements, representations and understandings.

By signing this agreement, Requestor accepts the terms indicated above.

________________________________________________________________________

Signature of Requestor                                                                                               Date

Print Name of Requestor:____________________________________________________

Print Name of Organization (if applicable) _______________________________________

Address:_________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Phone:_____________________________ Fax:___________________________________

E-mail:____________________________________________________________________

 

When signed by an authorized agent of The Ohio State University, this form constitutes permission for use as outlined in this agreement.

_________________________________________________________________________

The Ohio State University                                                                                          Date

 

Please return this form by (date) ___________   to:______________