Application for Copyright Clearance of Government of Canada Works Privacy Statement
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Crown Copyright File No.:  Application for Copyright Clearance of Government of Canada Works
Privacy Statement Provision of the information requested on this form is voluntary. The personal information collected is to be used to respond to your request for copyright clearance on Government of Canada works. We may share this information with other government departments if your inquiry relates to these departments. An incomplete form may result in the rejection of your request or a time delay in processing your request. The personal information will be maintained in the Personal Information Bank of [INSERT DEPARTMENT NAME HERE], number [PPU NUMBER HERE] and it will be protected, used and disclosed in accordance with the Privacy Act. Under this Act, you have the right to access your personal information and request changes to incorrect information. The information will be retained by the Department indefinitely until the retention and disposal schedule is determined and then disposed accordingly.  For assistance in completing this form, please contact us at the coordinates shown on the last page of this form. Please note that this form applies to [DEPARTMENT NAME] works only, and that all fields marked by an asterisk (*) must be completed.
1. APPLICANT INFORMATION (*) Complete Name: Title (Mr., Mrs., Ms.), First Name and Last Name Organization (*) Type of Organization (*) Postal Address (*) City/Town (*) Province/State (*) Postal/Zip Code (*) Country (*) Telephone Number Facsimile Number E-Mail Address Web Site Address (*) If permission is granted, person/organization in whose name permission is to be issued Individual named above Organization named above Other (Specify below) 
2. INFORMATION ON THE APPLICANT’S WORK (*) Purpose Reproduction Adaptation Revision Translation (Specify languages of your work below) N.B. If the [DEPARTMENT NAME] material has been adapted or revised, copies of your adapted/revised work and the [DEPARTMENT NAME] material must be included with your request. (*) Title of your work (*) Format(s) in which your work will be produced Audio CD Audiocassette Braille CD-ROM Diskette DVD Electronic / Internet Large Print Map Microfiche Paper Videocassette (*) End Use Commercial Non-commercial Cost-recovery Promotional (*) Sale or Cost-recovery Price (*) Number of Copies to be printed/produced OR (*) URL(s) for Web page(s) where the work will be published 
Crown Copyright File No.: 3. INFORMATION ON THE GOVERNMENT OF CANADA WORK (*)Title of Crown Work Year / Date of Publication YYYY (*) Format of Source Material Audio CD Audiocassette Braille CD-ROM Diskette DVD Electronic / Internet Large Print Map Microfiche Paper Videocassette (*) Reference Numbers (ISBN, ISSN, Catalogue / Publication Number) OR (*) Exact URL where source material is published (*) Precise description of material to be used Database Figure Footage Illustration Logo Map Photo Table Text Whole Work Other (Specify additional information below) Volume / Issue Page No(s) Table / Figure No. Image / Photo No. / Description Additional Information (If you require more space, please attach a separate sheet)
 Crown Copyright File No.:
4. ADDITIONAL INFORMATION Applicant Reference Number (If you wish to assign one) I would appreciate a response by yyyy/mm/dd Have you previously received approval to use the same material(s)? Yes No If yes, previous Crown Copyright File No. 
Please address all correspondence to: 
Environment Canada Inquiry Centre 10 Wellington Street, 23rd Floor Gatineau QC K1A 0H3
Toll Free: 1-800-668-6767 (in Canada only) Facsimile: 819-994-1412 Teletypewriter: 819-994-0736 Email: enviroinfo@ec.gc.ca Application for Copyright Clearance of Environment Canada Works / 4 Application for Copyright Clearance of Environment Canada Works |