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Application for Copyright Clearance

This form applies for Health Canada and the Public Health Agency of Canada requests only. Please note that all fields with an asterisk (*) are mandatory.

1. Applicant Information

* 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 material has been adapted or revised, copies of your adapted/revised work and Public Health Agency of Canada's material must be included with your request.

* Format(s) in which your work will be produced
* End Use
* Territory where your work will be distributed

3. Response

4. Other

Have you previously received approval to use the same material(s)?

5. Information on the Work

* Format of Source Material
* Reference Numbers
* Precise description of material to be used

6. Applicant's Reference No.

7. Contact Information

If you need assistance in completing this form, please contact the Publishing and Copyright Administrative Officer listed below. Please address all correspondence to:

Louise Sicard
Publishing and Copyright Administrative Officer
Public Affairs Directorate
Brooke Claxton Building, Basement, Room 0120C
Ottawa ON K1A 0K9

Telephone: 613-960-0625
Cell.: 613-816-6053
Facsimile: 613-941-5366