Print-out this Reprint Permission Form for the reprint(s) you wish to purchase.
Then complete it and mail it in with any required payment (in US FUNDS)
to the address shown below. Thank You.
GENE LEVINE ASSOCIATES REPRINT PERMISSION FORM
PLEASE PRINT OR TYPE
YOUR NAME: _________________________ POSITION:________________DATE:_______
ORGANIZATION:_______________________________________________________________
ADDRESS:__________________________________________________________________
CITY:__________________ STATE____ COUNTRY:__________ POSTAL CODE:_______
We will grant permission either by: (1) signed statement sent via US mail, or (2) digitally signed email.
If you would like confirmation by E-Mail,
Please supply us with your E-Mail Address: __________________________________
I/we hereby request permission to reprint the following articles:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
I/we desire to reprint and distribute them in the following manner: ___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
I/we desire to reprint and distribute them for the purpose of: _________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Enclosed is a check in US Funds for: US$______________
covering the reprint license fees specified in G.L.A.s
"Rules Governing Use of Proprietary G.L.A. Materials and/or Reprints."
Please Print or type the name of the person signing below: _________________________________________________________
Signed __________________________ Date __________________
Mail a copy of this form and payment (made payable to Gene Levine)
Gene Levine
2512 NW 82nd St.
Gainesville, FL 32606
====================== Please Do not write below this line ====================
___Approved ___Disapproved Date_________ Received $______________
Permission for reprinting sent by:
____ Digitally signed e-mail message ____ US Mail
Form 785293 - Revised: 2015
