Copyright and Reprint Permissions Submission Form
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All of the below options mareked with an asterisk (*) must be completed to submit a requst for reprint permission.
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Name of Requestor:
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Company Name: (address/state/zip/country)
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Phone Number:
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Fax Number:
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Email:
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Title of APTA Publication:
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Article Title:
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Volume/Issue, Number/Year/Page Numbers (all that apply)
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Figures/Tables Numbers (if applicable)
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Title/Type of Publication or other vehicle in which APTA material will appear (eg., journal, book, brochure, Web-site, CE course, presentaton, classroom curriculum)
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Estimated size and Demographic of Audience, or Print Quantity of Publication
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Scope of Permission (Please click on all that apply)
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One time use
Single edition of a publication
All current and future editions
US distribution
Worldwide distribution
Print only
Electronic only
Print and electronic
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Requestor is an Author of the Material Being Sought:
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No
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Will publication be distributed for resale?
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Yes
No
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If material is to be adapted, provide the proposed revised text or graphic via fax, e-mail, or mail.
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Fax, e-mail, or mail to:
APTA
Publications Dept.
1111 N. Fairfax Street
Alexandria, VA 22314-1488
Fax: (703) 706-3169
E-mail: Permissions@apta.org
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