Application for Copyright Clearance

This form applies for Health Canada and the Public Health Agency of Canada requests only. Please note that all fields with an asterisk (*) are mandatory.

1. Applicant Information

Name (required)

Organization (if applicable)

Postal Address (required)

City (required)

Province/State (required)

Postal/Zip Code (required)

Country (required)

Telephone No. (required)

Facsimile No.

E-mail Address (required)

Web Site Address (if applicable)

If permission is granted, person/organization in whose name permission is to be issued (required)

Individual named above

Organization named above

Other

Other (please specify):

2. Information on the applicant's work

Purpose (required)

Reproduction

Adaptation

Revision

Translation

If Translation, specify the language of your work.

N.B. If the material has been adapted or revised, copies of your adapted/revised work and Public Health Agency of Canada's material must be included with your request.

Format(s) in which your work will be produced(required)

Paper

Internet

CD-ROM

Video/Film

Audio Diskette

DVD

Other

Other (please specify):

Number of copies to be printed / produced OR Specific URL(s) for web page(s) where your work will be published:

End Use (required)

Commercial

Non-Commercial

Educational

Free Distribution

Advertising/Promotion

Other

Other (please specify):

Commercial sale price OR price for works produced on a cost-recovery basis:

Territory where your work will be distributed (required)

Canada

World-wide

Other

Other (please specify):

3. Response

I would appreciate receiving a response by: (YYYY-MM-DD)

4. Other

Have you previously received approval to use the same material(s)?

Yes

If yes, previous approval date. (if available) (YYYY-MM-DD)

5. Information on the Work

Title: (required)

Year/Date of publication: (YYYY-MM-DD)

Format of Source Material (required)

Paper

Internet

CD-ROM

Video/Film

Audio Diskette

DVD

Other

Other (please specify):

Reference Numbers

ISBN or ISSN:

Catalogue Number:

Publication Number:

OR Exact URL where source material is published:

Precise description of material to be used

Volume/Issue:

Page No(s):

Table No./Figure No.:

Image/Photo No./Description:

Additional Information

6. Applicant's Reference No.

(If you wish to assign one)

7. Contact Information

If you need assistance in completing this form, please contact the Publishing and Copyright Administrative Officer listed below. Please address all correspondence to:

Louise Sicard
Publishing and Copyright Administrative Officer
Public Affairs Directorate
Brooke Claxton Building, Basement, Room 0120C
Ottawa ON K1A 0K9

Telephone: 613-960-0625
Cell.: 613-816-6053
Facsimile: 613-941-5366
E-mail: Pubsadmin@hc-sc.gc.ca

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Date modified:: 2021-02-23

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Application for Copyright Clearance

1. Applicant Information

2. Information on the applicant's work

3. Response

4. Other

5. Information on the Work

6. Applicant's Reference No.

7. Contact Information

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