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

Other:

2. Information on the applicant's work

Purpose

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

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

*End Use

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

*Territory where your work will be distributed

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

Reference Numbers

(ISBN, ISSN, Catalogue/Publication Number)

OR

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)