FACULTY SERVICES
COPYRIGHT CLEARANCE REQUEST FORM
TELEPHONE: (717) 691-6023 FAX: (717) 691-6040
EMAIL: FACSERV@MESSIAH.EDU
PLEASE FILL IN EACH SECTION LEGIBLY -- DUPLICATE FORM AS NEEDED
updated 5-1-2010
SECTION I – INSTRUCTOR & COURSE INFORMATION
PROFESSOR NAME:
TERM/SEMESTER
(CHECK ONE):
DATE:
J-TERM
SPRING
SUMMER
FALL
YEAR:
COURSE NAME:
COURSE NO.
# OF SETS NEEDED:
SECTION II – USE OF MATERIAL (CHECK ONE)
SOLD AT TEXTBOOK EXPRESS (COURSEPACK/READER)
ELECTRONIC/DIGITAL FORM (I.E., LEARNING
M ANAGEMENT SYSTEM (LMS), INTERNET)
DISTRIBUTED IN CLASSROOM
POST DATE (FROM):
PLACED ON LIBRARY RESERVE
POST DATE (TO):
REPUBLICATION
OTHER (PLEASE SPECIFY)
SECTION III – COURSEPACKS, CLASSROOM HANDOUTS, LIBRARY RESERVES (PAPER COPIES)
Complete as accurately and completely as possible. Duplicate form as needed.
1
OUT- OF- PRINT
WORK?
BOOK OR JOURNAL TITLE:
YES
NO
CHAPTER OR ARTICLE NAME:
AUTHOR(S)/EDITOR(S):
ISBN #:
PUBLISHER:
PUBLISHING/COPYRIGHT YEAR:
PAGE NUMBERS:
2
VOLUME #:
FROM:
To:
TOTAL PAGES:
FROM:
To:
TOTAL PAGES:
EDITION:
OUT- OF- PRINT
WORK?
BOOK OR JOURNAL TITLE:
YES
CHAPTER OR ARTICLE NAME:
AUTHOR(S)/EDITOR(S):
ISBN #:
PUBLISHER:
PUBLISHING/COPYRIGHT YEAR:
PAGE NUMBERS:
VOLUME #:
FROM:
To:
TOTAL PAGES:
FROM:
To:
TOTAL PAGES:
EDITION:
NO
3
OUT- OF- PRINT
WORK?
BOOK OR JOURNAL TITLE:
YES
NO
CHAPTER OR ARTICLE NAME:
AUTHOR(S)/EDITOR(S):
ISBN #:
PUBLISHER:
PUBLISHING/COPYRIGHT YEAR:
PAGE NUMBERS:
4
VOLUME #:
FROM:
To:
TOTAL PAGES:
FROM:
To:
TOTAL PAGES:
EDITION:
OUT- OF- PRINT
WORK?
BOOK OR JOURNAL TITLE:
YES
NO
CHAPTER OR ARTICLE NAME:
AUTHOR(S)/EDITOR(S):
ISBN #:
PUBLISHER:
PUBLISHING/COPYRIGHT YEAR:
PAGE NUMBERS:
VOLUME #:
FROM:
To:
TOTAL PAGES:
FROM:
To:
TOTAL PAGES:
EDITION:
SECTION IV – ON-LINE COURSE (MULTIMEDIA)
Complete this section if using DVD/Video streaming, film and television show clips, audio CD clips, and documentaries.
1
TITLE:
DO STUDENTS HAVE TO
PURCHASE TEXTBOOK?
DOES MESSIAH OWN PUBLIC
PERFORMANCE RIGHTS?
NUMBER OF
STUDENTS:
PUBLISHER:
PRODUCER/DIRECTOR:
AUTHOR/WRITER:
DISTRIBUTOR:
COPYRIGHT YEAR:
COURSE URL:
SECTION V – ELECTRONIC DISTRIBUTION
Complete this section if placing a copyrighted document in LMS (Sakai).
1
BOOK OR JOURNAL TITLE:
CHAPTER OR ARTICLE NAME:
AUTHOR(S)/EDITOR(S):
ISBN #:
PUBLISHER:
PUBLISHING/COPYRIGHT YEAR:
PAGE NUMBERS:
VOLUME #:
FROM:
To:
TOTAL PAGES:
FROM:
To:
TOTAL PAGES:
EDITION:
YES
NO
YES
NO