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Permission Request Form

To request permission to reproduce all or part of material found on the Manitoba government website, film, video or publications available in print, please complete the following form:

Fields marked with an asterisk (*) are required.

Requested by:

First name: *	Last name: *
Company name:
Address: *	City: *
Province: *	Postal Code: *
Phone number:*	Email address:
Fax:

Source Information:

Is this material from a : * Publication Website ?

If a publication, please specify the following:

Publication Title: *
Author or Government Department (if applicable):
Page #'s to be reproduced or adapted: *

If a website, please specify the following:

Source URL:*

Intended Use:

Number of copies to be reproduced: *

Intended Use (please check): *
Commercial (Are you profiting from distribution of the material?)
If Commercial, please specify: Price: *

Non-commercial: (Will you be giving the material away free of charge?)

Educational (Are you a university, college, pre-school, elementary, secondary, non-profit organization created by law?)
If Educational, are you selling materials to recover production costs? Yes: No:

Please provide all relevant details, including the purpose served by the proposed work, contact information for any other persons or parties involved in the production or distribution of the proposed work:

Should you have inquiries about your request, please contact copyright@gov.mb.ca for further information.