Copyright Permission Service request Please complete the following form if you require permission from a copyright owner to use their material in any teaching, learning or research activity in your capacity as a La Trobe University staff member, or as a Graduate Research student for use in a thesis, research project or published paper.Please provide accurate information to ensure your request is handled promptly. Required fields are marked with an asterisk (*). Your details Name * Email address * (Please ensure this is your La Trobe University email address) Contact number Organisation/Department * Copyright details Type of material * -- Please Select --BookJournal articleFigure/GraphPhotographVideoSongOther What kind of work is the material? * Full citation of the material you want to use * (Please provide as much detail as you can, e.g. title, author/creator/director, publisher, date, ISSN/ISBN) Who owns the copyright of the material? * (Please include their contact details, e.g. an organisation, an individual) Source/Location of the material * (e.g. a URL if it is online) Do you want to use the full item? * Yes No, only part of it Please specify the amount you want to use * (e.g. section, page range) Do you plan to adapt/modify the material in any way? * Yes No How do you plan to modify the material? * Please describe where the material will be used * (e.g. in a restricted access platform for only staff and students of LTU, in an open access publication) How long do you intend to use the material for? * (e.g. one semester, indefinitely) When do you need to receive the permission by? * Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJuneJulyAugSeptOctNovDec Year 202420252026 Confidentiality La Trobe University respects the privacy of your personal information. We collect personal information about you to help us provide the most relevant learning support. We will use only use the supplied information for this purpose. If your personal information is not provided to us, then we may not be able to contact you to set up an appointment, or may not assign your case to the most relevant expert advisor. You may have the right to access the personal information we hold about you, subject to any exemptions in relevant laws, by contacting us. Refer to the La Trobe University privacy policy for more details. Information in this form has been adapted from the University of Melbourne Copyright Office and is used with permission from University of Melbourne.
