Educational Materials Copyright Clearance Template
Requestor Information
Name
Department/Organization
Email
Date
Material Details
Title of Material
Author(s) / Creators
Publisher / Source
Type of Material
Full Citation or Reference
Link to Material (if applicable)
Usage Details
Intended Use (e.g., classroom, online, print)
Number of Copies / Audience Size
Course/Project Name (if applicable)
Duration of Use
Specific Portion to Be Used (e.g., pages, chapters, figures)
Permission Information
Source of Permission
Date Permission Requested
Date Permission Received
Permission Details / Restrictions
Additional Notes