Republication/Electronic Request Form

First Name:
Last Name:
Name of Company or Organization:
Your Address (City, State/Province, Zip/Postal Code, Country):

Contact Phone Number:
Fax:
E-mail Address:
E-mail Address (Reprise):

Title and authors of paper in ATCS which you’d like to reprint:

Journal Month, Year and Volume:
Journal Issue Number:

Style of Your Use:
As		a part of the materials (up to 300 words of text and/or 8 figures/tables)
		a whole
		a summary (revision)
Specific pages or range of pages of text and/or figure/table numbers you wish to reproduce:

Format of Your Work:
	Print:
	CD-ROM:
		What is the size of the print run (in number of copies)?

	E-Book:
		Reader Type (Adobe Acrobat or Microsoft):
	WWW:
		What is the URL where the material would be located?

		Is the material requested from an adopted textbook used for a college course?
		Yes No
		Is the web site where the material will be posted password protected, or is access to the site limited in any way?
		Yes No
		What is the instructor's or professor's name?

		What is the name and number of the course?

		How many users would have access?
		How long will the material be posted (not to exceed a two year limit)?
		From: (dd/mm/yyyy)
		To: (dd/mm/yyyy)
	Intranet:
		What is the URL where the material would be located?

		Is the material requested from an adopted textbook used for a college course?
		Yes No
		Is the web site where the material will be posted password protected, or is access to the site limited in any way?
		Yes No
		What is the instructor's or professor's name?

		What is the name and number of the course?

		How many users would have access?
		How long will the material be posted?
		From: (dd/mm/yyyy)
		To: (dd/mm/yyyy)
	Software Program: (i.e. Powerpoint, database, disk)
		What is the size of the print run (in number of copies)?

Please indicate any unusual circumstances regarding this request (such as you are the author of the requested material)