Reprint Request Form

Requester Name:

Organization:

• Nonprofit
• For profit

Organization's purpose:

Address 1:

Address 2:

City:      State:      ZIP:

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I am requesting permission to nonexclusive rights to reprint the PACER Center material described below:

Publication title:

Publication date:

Title of article (if applicable):

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From page: To page
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Publication Information:

I am requesting nonexclusive North American rights in the publication's original language to reprint the above-named PACER material as follows:

My publication name:

Format of publication (e.g., book, newsletter, overhead, Web page, audiotape)

Purpose of publication:

Target audience:

Project will be sold Yes    No

Subscription rate/unit price: $

Estimated print run/circulation:

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* I will cite the following credit line:

From [Publication Title], by [Author], © [copyright year]. Used with permission from PACER Center Inc., Minneapolis, MN, (952) 838-9000. www.pacer.org. All rights reserved.

I am using PACER material exactly as it appears in the original publication

or

I would like to adapt the text of PACER material. (If so please send a copy of the material as it will appear in your publication to: Reprint Coordinator, PACER Center, Inc., 8161 Normandale Blvd., Minneapolis, MN, 952-838-9000.)

Please allow 10 to 15 business days for a response. If more information is needed or special arrangements are required, additional time may be needed to process your request.