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Application for Copyright Clearance on Health Canada Works

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The material on the Health Canada is covered by the provisions of the Copyright Act, by Canadian laws, policies, regulations and international agreements. Such provisions serve to identify the information source and, in specific instances, to prohibit reproduction of materials without written permission.

To submit your request for copyright permission, please complete the following form. The personal information you provide is collected to allow Health Canada to evaluate your request and to inform you of the decision. This personal information is protected under the Federal Privacy Act. Accordingly, it will be used, retained and disclosed for the purpose mentioned above only. Learn more about our commitment to privacy.

If you prefer to submit your request through mail or fax or if would like to obtain information concerning copyright ownership and restrictions on reproduction on this site, please contact:

Publishing Administrative Officer
Marketing and Creative Services
3^rd Floor, Jeanne Mance Building, A/L 1903D
Ottawa ON K1A 0K9
Telephone: (613) 957-2970
Facsimile: (613) 957-1395
E-Mail: Pubsadmin@hc-sc.gc.ca

Application for Copyright Clearance on Health Canada Works - PDF Version

Please note that this form applies to Health Canada works only, and that all fields marked by an asterisk (*) must be completed.

1. Applicant Information

*Complete Name:
Organization:
*Postal Address:
*City/Town:
*Province/State:
*Postal/Zip Code:
*Country:
*Telephone No.:
Facsimile No.:
*E-Mail Address:
Web Site Address: (recommended)

If permission is granted, person/organization in whose name permission is to be issued
Individual named above	Organization named above
Other

2. Information on the applicant's work

Purpose
Reproduction Adaptation Revision
Translation (specify the language of your work)

N.B. If the Health Canada's material has been adapted or revised, copies of your adapted/revised work and Health Canada's material must be included with your request.

*Format(s) in which your work will be produced
Paper	Internet	CD-ROM
Video/Film	Audio	Diskette
DVD	Other:

*Number of copies to be printed / produced OR Specific URL(s) for Web page(s) where your work will be published

*End Use
Commercial	Non-Commercial
Educational	Free Distribution
Advertising/Promotion	Other:

Commercial sale price or price for works produced on a cost-recovery basis

*Territory where your work will be distributed
Canada World-wide Other:

3. Response
I would appreciate receiving a response by: Month/Day/Year

4. Other

Have you previously received approval to use the same material(s)?
Yes No

If yes, previous approval date. (if available)

5. Information on Health Canada's work

*Title of Health Canada's work:
Year/Date of publication:

*Format of Source Material
Paper	Internet	CD-ROM
Video/Film	Diskette	Audio tape
DVD	Other :

Reference Numbers

(ISBN, ISSN, Catalogue/Publication Number)

Exact URL where source material is published

*Precise description of material to be used

Volume/ Issue:
Table No./ Figure No.
Page No(s):
Image/ Photo No./ Description

Additional Information

6. Applicant's reference No.
(If you wish to assign one)


	Last Updated: 2006-05-19		Important Notices