FOR GOOD CONSIDERATION， the undersigned， as copyright holder¹， hereby grants permission to _， to reprint， publish and use for world distribution the following material： [Describe or attach]

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　　This material shall be used only in the following manner or publication：  [Define intended use]

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　　A credit line to acknowledge use of the material is _____ is not _____ [Check one] required.  If required， the credit line shall read as follows：

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　　Dated： _

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