Permissions Request Form
* denotes required fields

Name *

First

Last

Title/Position

Institution/Orgnanizational Name *

Address *

Street Address
Address Line 2
City	State / Province / Region
Postal / Zip Code	Country

Phone

###

####

Email *

Are you a member of the American Hospital Association or any of its Personal Membership Groups? *

Yes

If yes, please describe how you are a member and include your member number:

If no, would you like information about membership to the American Hospital Association or any of its Personal Membership Groups?

Yes

Title of the Publication/Work Being Requested: *

Volume/Issue or Publication Date (if known and/or applicable):

Specific Pages/Sections/Figures/Tables/URLs to Be Copied:

Print quantity of publication: *

Estimated size and occupation of audience: *

Is this for one time use? *

Yes

If no, please explain:

Formats: *

Print only

Electronic only

Print and Electronic

Other

Please briefly describe how it will be used: *

The primary purpose of this use is: *

Educational

Commercial

Other

Please briefly explain: *

Requestor is an author of the material being sought: *

Yes

Additional information you would like to share that may assist with your request:

*Please note that this is only a request and not a grant of permission. If approved, a Permissions Agreement will be sent to you for signature and is not in effect until signed by both parties and all fees are paid (if applicable).