Permission to Use Literary Work:  Release Form

I, the author whose signature appears below, authorize the use of my donated/ copied work entitled  

________________________________________________________________

that is dated ______________ ______, _____, concerning

_________________________________________________________________

and related subjects, for educational purposes and for research use by scholars, with the understanding that my permission need [   ] / need not [   ] be secured prior to publication of any part of their contents other than that which constitutes fair use under the copyright law of the United States (title 17, United States Code).   (If neither box is checked, the default is that the permission need not be secured.)

Signature of Author ________________________________________     Dated: _______________

Author's name as he/she wishes it to be used: _____________________________________________

Author's permanent address: _____________________________________________________________________
                                               (street or post office box)              (city)                 (state)           (zip/ postal code)

Author's phone number: (____) ______- _________       Email address ___________________________

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Page last modified: July 06, 2004