Educational Materials Copyright Clearance Template

Name Department/Organization Email Date Title of Material Author(s) / Creators Publisher / Source Type of Material Full Citation or Reference Link to Material (if applicable) 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) Source of Permission Date Permission Requested Date Permission Received Permission Details / Restrictions