Doing What’s Best for Kids

General Administration AP 190 - Form 190-3: Copyright Permission Form

Permission is requested to reproduce the following copyrighted material(s):

Title of work:

Format Modification/Translation

Braille     Audiotape     Large Print

 Excerpts or Adaptation (see attachment) Other

Use of Materials 

 Classroom Use (specify)

 Special Circumstances (e.g., class newsletter, etc.)

Copyright Owner

Permission is hereby granted to  of   school to photocopy the material as specified above.

Credit Statement: 

Under the Following Conditions: 

Authorized by: