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