Permission to Use Likeness and/or Copyrighted Material

Permission to Use Likeness and/or Copyrighted Material
Your Information
Name*

First NameLast Name
Member Number
Email*
example@example.com
Phone Number*
Example: +01 (555) 555-5555
Organization*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Material Requested
Type of Material*

LogoTextGraphicsVideoOther
Logo Details*
Text/Graphic Details
Title*
Publication*
Page Number*
Author*
Author Permission Verified*

YesNo
Video Details
Video Title*
Publication*
Intended Use of Copyrighted Material
Title of Publication*
Date of Publication

MonthDayYear
Date
Number of Copies/Circulation
Format*

PrintDigital
Distribution
Description of Intended Use*
Terms of Use
Permission by the ISEE to use copyrighted materials shall apply only to the use as described in this form. Permission to use copyrighted materials does not constitute a transfer of ownership of rights.
I agree to the terms of use outlined above.*

Yes
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Intended Use of Copyrighted Material