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Agreement To Reprint Copyrighted Material

(by non-profit organization)

This Agreement is by and between [Name and Address of Copyright Holder], hereinafter referred to as Holder, and [Name and Address of Non-Profit Organization], hereinafter referred to as Organization, on this [Date], do hereby agree to the following:

Recitals. Organization, is preparing education materials for the purpose of teaching (subject of teaching). The foregoing mentioned instruction materials will be used (for and/or in)

(Enumerate the foregoing)

and will be produced in (number) (books and volumes) copies.

Distribution. The total distribution is expected to be approximately (--) copies. The finished material on the entitled (title) subject matter herein, will be distributed without profit or personal gain of any form whatsoever. In light of the above mentioned guidelines, Organization does hereby request permission from Holder to reprint the following material:

(Enumerate)

In addition, Organization will include a credit line in the (preface/reproduction) which states the following:

Copyright. This material was reprinted from (name of original publication), with permission from (copyright holder/owner) copyright (year). With the signing of this document permission is hereby granted to Organization to reprint the previously mentioned copyrighted material.

This agreement is the entire agreement between the parties, and may only be altered by an instrument in writing.

Executed on the date as first above written at (City/State).

Signature

Copyright Holder / Owner

Signature

Organization

This Section for Notary:

Acknowledgment

STATE OF -------)

) ss: [date]

COUNTY OF ------)

On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal.

[signature]

[Name of Notary Public]

My commission expires: [date]

(Seal)