FOR GOOD CONSIDERATION， the undersigned， as copyright holder1， hereby grants permission to _， to reprint， publish and use for world distribution the following material： [Describe or attach]
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This material shall be used only in the following manner or publication： [Define intended use]
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A credit line to acknowledge use of the material is _____ is not _____ [Check one] required. If required， the credit line shall read as follows：
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Dated： _
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