For good consideration, the undersigned, as copyright holder, hereby grants permission to ____________________, to reprint, publish and use for world distribution the following material: _____________________________________________________ _____________________________________________(Describe or attach).

This material shall be used only in the following manner or publication: _____________

_________________________________________________________ (Define intended use).

A credit line to acknowledge use of the material is _____ is not _____ (Check one) required. If required, the credit line shall read as follows: ___________________________________________

Dated: ________________

_______________________________

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