FOR GOOD CONSIDERATION, the undersigned, as copyright
holder, hereby grants permission to _, to reprint, publish and
use for world distribution the following material: (Describe
or attach)

_

This material shall be used only in the following manner
or publication: (Define intended use)

_

A credit line to acknowledge use of the material is _____
is not _____ (Check one) required. If required, the credit
line shall read as follows:

_

Dated: _

_______________________________