999 Avenue H N.E. Winter Haven, Florida 33881

Request to Duplicate
Copyrighted Material



 Copyright Holder:


 Request From:


 Date of Request:


 Postion or Title:


 Company Name:


 School District:


 Address:


 Address:


 City, State Zip:


 City, State Zip:



I / WE REQUEST PERSMISSION TO DUPLICATE THE FOLLOWING COPYRIGHTED MATERIAL



 Title:


 Author(s):


 Date of Publication:


 Subject:


 Medium:


Reason/Purpose for Request:




 Number of Copies to be Made:


 Copy Medium:


 Date Copies are Required:


Method of Distribution:


 

 

Request to Duplicate
Copyrighted Material

COPYRIGHT HOLDER REPLY


 Request Granted

 

 Request Refused

 

 Restrictions and other information




 Signature:


Title:


Date:


 

Please Return to Requestor at
Polk Community College
999 Avenue H N.E.
Winter Haven, Florida 33881