Crown Copyright File No.: ________________________
Application for Copyright Authorization of Employment and Social Development
Canada Works
Privacy Statement
The information you provide is collected in accordance with the Privacy Act, to be used to respond to your request for
copyright authorization to use Employment and Social Development Canada (ESDC) works. Participation is voluntary.
Refusal to provide personal information may result in the rejection of your request or a delay in processing your request.
The information you provide may be shared with other federal government departments for the purpose of responding
to your request. The information you provide may be used and/or disclosed for policy analysis, research and/or
evaluation purposes. In order to conduct these activities, various sources of information under the custody and control
of Human Resources and Skills Development Canada (HRSDC) may be linked. However, these additional uses
and/or disclosures of your personal information will never result in an administrative decision being made about you.
Your personal information is administered in accordance with the Department of Human Resources and Skills
Development Act, the Privacy Act and other applicable laws. You have the right to the protection of, and access to,
your personal information. Instructions for obtaining this information are outlined in the government publication
entitled Info Source, which is available at the following address: http://www.infosource.gc.ca. Info Source may also be
accessed online at any Service Canada Centre.
For assistance in completing this form, please contact us at the coordinates shown on the last page of this form. Please note
that this form applies to Employment and Social Development Canada only.
1. APPLICANT INFORMATION
(*) Complete Name: Title (Mr., Mrs., Ms.), First Name and Last Name
Organization
(*) Type of Organization
(*) Postal Address
(*) City/Town
(*) Province/State
(*) Telephone Number
(*) Postal/Zip Code
Facsimile Number
(*) Country
E-Mail Address
Website URL
(*) If permission is granted, person/organization in whose name permission is to be issued
Individual named above
Organization named above
Other (Specify below)
Crown Copyright File No.: ________________________
2. REQUEST
(*) Purpose
Reproduction
Adaptation
Revision
Translation (Specify languages of your work below)
Other details
(*) Title of work
(*) Format(s) in which your work is being produced
Audio CD
Audiocassette
Braille
CD-ROM
Diskette
DVD
Electronic / Internet
Large Print
Map
Microfiche
Paper
Videocassette
Non-commerciale
Cost-recovery
(*) End Use
Commercial
(*) Sale or Cost-recovery Price
(*) Number of Copies of to be printed/produced
OR
(*) URL(s) for Web page(s) where the work will be published
Promotional
Crown Copyright File No.: ________________________
3. INFORMATION ON THE GOVERNMENT OF CANADA WORK
(*) Title of Crown Work
Year / Date of Publication
YYYY
(*) Format of Source Material
Audio CD
Audiocassette
Braille
CD-ROM
Diskette
DVD
Electronic / Internet
Large Print
Map
Microfiche
Paper
Videocassette
(*) Reference Numbers (ISBN, ISSN, Catalogue / Publication Number)
OR
(*) Exact URL where source material is published
(*) Precise description of material to be used
Database
Figure
Footage
Illustration
Logo
Map
Photo
Table
Text
Whole Work
Other (Specify additional information below)
Volume / Issue
Page No(s)
Table / Figure No.
Image / Photo No. / Description
Additional Information (If you require more space, please attach a separate sheet)
Crown Copyright File No.: ________________________
4. ADDITIONAL INFORMATION
Applicant Reference Number (If you wish to assign one)
I would appreciate a response by
yyyy/mm/dd
Have you previously received approval to use the same material(s)?
Yes
No
If yes, previous Crown Copyright File No.
Please address all correspondence to:
Employment and Social Development Canada
Creative Services
140 Promenade du Portage, Phase IV, 10th Floor
Gatineau, QC
Canada
K1A 0J9
OR
Email: droitdauteur.copyright@hrsdc-rhdcc.cg.ca