COPYRIGHT REQUEST FORM
Learning Resource Services
Copyright Office
Copyright Request #: ____________
345 6 Avenue SE
Calgary AB T2G 4V1
Date of Request:
Local Phone #:
Requestor’s Name:
Department:
Title of BVC course/publication material will be used in:
Course Code:
Description of Material to be used: (Attach a copy of the copyright pages.)
Title:
Title of Excerpt:
Author/Editor:
Format of Work:
Publisher:
Book
Textbook
Magazine/Newspaper
Government Publications
Video/Audio/CD
Internet Site
Other:
ISBN/ISSN Number:
Edition:
Volume Number:
Issue #:
Year:
Issue Date: (mo/yr)
URL: (attach
Yes
Out of Print:
No
list if needed.)
Material to be Released: (Attach a copy of the requested material.)
Chapters, Page Numbers, material to be duplicated:
Total # of pages used:
Total # of Pages in Material:
# of Copies to be made:
How Material will be used:
Number of people who will access the material:
Purpose: (Check as
many as apply.)
Classroom Handout
Reading Collections
Print Study Guides
Is the material to be revised?
No
Duration access to material is needed:
Internet Link
WebCT
LRS Circulation
Testing Materials
Other uses:
Yes (If yes, attach a copy highlighting the revisions.)
Description: (how will the learners be using the material)
Will the material be sold?
(Check as many as apply.)
No, given to Bow Valley College Students only
No, given to individuals/organizations outside of Bow Valley College
Yes, to Bow Valley College Students only
Yes, to individuals/organizations outside of Bow Valley College
Date/Semester(s) Required:
For Learning Resource Services Use Only
Access Copyright
Access Copyright Ref. #:
Publisher/Rights Holder Info.
Pub. Ref. #:
Name:
Address:
Phone:
FAX:
Email:
Publisher URL:
Date forwarded to copyright holder:
Publisher Reference #:
Date returned from copyright holder:
Date instructor/services notified:
Restrictions:
Charge Code:
Fees:
LRS Approval (Signature):
Date:
GST:
Rev May 2014