Reprint Permission Request

Please use this form when requesting permission to reprint or reproduce any publication, program, product (e.g., including but not limited to publications, audio and visual materials) of Michigan Protection and Advocacy Service, Inc. (MPAS). You can fill in this form and submit it on-line or print this form, complete it, and fax or mail it to us.
NOTE: Simply printing a hard copy of MPAS materials for personal or private use does not require permission.

(** Denotes a required field)

**Requester Name:
Organization:
	Non-profit For profit Individual
Organization's Purpose:
**Address 1:
Address 2:
**City:
**State:
**Zip:
**Phone:	()
Fax:	()
E-mail Address:

I am requesting permission to nonexclusive rights to reprint the Michigan Protection and Advocacy Service material described below:

**Publication/Program/Product Material Title:
Publication/Program/Product Material Date:
Title of Article, Program, or Material (if applicable):
Author(s):
From Page:	to Page
Total Pages:
Publication/Program/Product Material Information:

I am requesting non-exclusive North American rights in the publication's original language to reprint the above-named Michigan Protection and Advocacy Service material in our publication, program, or product:

My Publication/Program/Product Name:
Format of Publication, Program, or Product (e.g., book, newsletter, overhead, Web page, audiotape):
Purpose of Publication/Program/Product:
Target Audience:
**Publication/Product/Project Will Be Sold:	Yes No
Subscription Rate/Unit Price: $
Estimated Print Run/Circulation/Attendance/Distribution:
Estimated Publication/Reproduction Date:

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.

	Michigan Protection & Advocacy Service, Inc.
*Lansing (517) 487-1755 TOLL FREE 1-800-288-5923 (Voice or TTY)**
*Fax (517) 487-0827 Email MPAS**