Reprints And Permission Request
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Reprints And Permission Request Form. This is a Connecticut form and can be use in Administrative Statewide.
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Tags: Reprints And Permission Request, JD-ES-209, Connecticut Statewide, Administrative
REPRINTS AND PERMISSION
REQUEST
JD-ES-209 New 4-06
NOTE: All republished material must carry Judicial Branch credit.
Unless specifically noted otherwise, all permission
is given for one-time use only.
CONNECTICUT JUDICIAL BRANCH
DIVISION OF EXTERNAL AFFAIRS
231 Capitol Avenue
Hartford, CT 06106
www.jud.ct.gov
Telephone Number: (860) 757-2270 Fax Number: (860) 757-2215
REQUESTOR IDENTIFICATION
NAME OF REQUESTOR (Last, first, middle initial)
DATE OF REQUEST
ORGANIZATION/AGENCY/DIVISION
TELEPHONE NUMBER
STREET ADDRESS
FAX NUMBER
CITY
STATE
ZIP
EMAIL ADDRESS
REQUEST DESCRIPTION
1.) List the material that you are seeking to reprint:
2.) State the purpose and manner in which the material will be used:
3.) Describe the mission of the organization seeking permission:
4.) State whether the material requested will be used for commercial purposes and if so, in what manner:
5.) Will a profit be derived from the use of the copyrighted material?
6.) Will there be a charge for the product or program that includes the copyrighted material?
7.) If the requested material is to be placed in a publication, provide the name of the publication, and the context in which the material
will appear:
8.) Estimated number of copies to be printed or produced. (If Intranet, number of users):
9.) Date(s) the material will be distributed:
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