permission to use copyrighted material form

PERMISSION TO USE COPYRIGHTED MATERIAL FOR GOOD AND VALUABLE CONSIDERATION, the receipt and sufficiency of which being hereby acknowledged, the undersigned, as the copyright holder, hereby grants permission to_____________________________, to reprint, publish and use for world distribution the following material: _________________________________________________ _________________________________________________ This material shall be used only in the following manner or publication: _________________________________________________ A credit line to acknowledge use of the material shall be required. The credit line shall read as follows: _________________________________________________ _________________________________________________ Dated this_____ day of_______________, 200(x). _______________________ __________________________ ___________________________________________________