Permission Request Form

Use this form for reprint and distribution requests.

Please indicate the type of usage you are requesting:*
- Reprint, republish or otherwise copy or distribute materials, e.g. printed documents, digital images, videos, CD-Roms or other media, which are owned or controlled by Accu-Glass;
- Use Accu-Glass's name in a press release or any other public document, including marketing and promotional materials. SUBMISSION OF A REQUEST IS THE FIRST STEP IN THE APPROVAL PROCESS; IT DOES NOT CONSTITUTE APPROVAL. ACCU-GLASS WILL NOTIFY YOU WHEN YOUR REQUEST HAS BEEN APPROVED.
Name*
FirstLast
Organization (Licensee)*
Name of Individual Authorized to Sign Permission Form (Signatory)
Relationship of Signatory to Licensee
Address*
Street AddressCityState / Province / RegionZip / Postal CodeCountry
Email*
Phone*
Relationship with Accu-Glass
Describe in detail the material(s) for which you request permission to reprint: (e.g., include a) the full title, author and copyright date of published article, as well as the document number, if known; or b) distinguishing characteristics of digital images and source description; or c) specific URLs for web page content; or d) full draft of the press release or other marketing material, etc.)
*
Catalog Number (if known)
Describe in detail for what purpose the material(s) will be used:
*
For What Duration will the Material(s) be Used?
Do You Have Samples of the Material(s) Requested?
- Yes
- No
Name of Your Accu-Glass Contact
Date Permission Required*
Before submitting personal information to us, we encourage you to read our Privacy Statement and Consent to Use of Data. This Statement contains important information about how we will handle and use your personal information. After you have had a chance to review the Statement, please acknowledge your acceptance of terms by selecting the box below. If you choose not to accept, the information you just completed will not be submitted to Accu-Glass.
*
- I accept the terms of the Privacy Statement.

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