Permission Request Form

* Required information

Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Untitled

* Required information

What material are you requesting permission to reprint?
Title*
Author*
Type of material
- Book
- Video
- Other
Please specify other
List the page numbers or video segments you wish to use
Number of people who will read or view the duplicated material*
Please enter a number greater than or equal to 1.
How will this material be used?
Where do you wish to reproduce the material?*
- In a textbook or journal article
- On a web site
- Other
Please specify other
Please provide specific information about how the material will be used. If applicable, provide the web address (URL) where the material will be reproduced.
Please provide your contact information so that we can send you a response.
Full name*
Title*
Organization*
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Email address*
Phone
Fax
If we approve your request, we will send you a form to sign and return to us. How would you like to receive this form?
Format*
- Email
- Fax
- Postal Service
Note: Because your signature and the signature of an Active Parenting staff member is required to complete this process, we must send you a form to sign and return. (If you choose the email option, you will need to print, sign, scan, and re-send the form.
What is your deadline for receiving a response?
Is there any additional information we should know?

What material are you requesting permission to reprint?