Application for Copyright Clearance of Government of Canada Works

Privacy Statement
The personal information collected is to be used to respond to your request for copyright clearance on Government of Canada works. Provision of the information requested on this form is voluntary. 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.

All personal information created, held or collected by the Department of Justice is protected under the federal Privacy Act. At any point of collection you will be asked for consent to collect your information, and you will be informed of the purpose for which it is being collected and how to exercise your right of access to that information.

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 the Department of Justice Canada 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

2. INFORMATION ON THE APPLICANT’S WORK

(*) Purpose

N.B. If the Department of Justice Canada material has been adapted or revised, copies of your adapted/revised work and the Department of Justice Canada material must be included with your request.

(*) Title of your work

(*) Format(s) in which your work will be produced

(*) End Use

(*) 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

3. INFORMATION ON THE GOVERNMENT OF CANADA WORK

(*)Title of Crown Work

Year / Date of Publication (YYYY)

(*) 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

Page No(s)

Table / Figure No.

Image / Photo No. / Description

Additional Information (If you require more space, please attach a separate sheet)

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)?

If yes, previous Crown Copyright File No.

Please address all correspondence to:

Department of Justice Canada
Communications Branch
Copyright administrator
284 Wellington Street
Ottawa, Ontario
K1A 0H8

Facsimile: (613) 948-2983   | Email: webadmin@justice.gc.ca

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