PACER Reprint Request Form

Please use this form when requesting permission to reprint any publication by PACER. You can either fill in this form and submit it via e-mail, or you may print this form out and fax or mail it in. Submission information is at the bottom of the form.

Question Title

* 1. Contact Information

Name *

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address *

Phone Number

Question Title

* 2. Organization Type

Nonprofit

For profit

School

Individual

Other (please specify)

I am requesting permission to nonexclusive rights to reprint the PACER Center material described below

Question Title

* 3. PACER Publication Title

Question Title

* 4. Publication date

Question Title

* 5. Title of Article (if applicable)

Question Title

* 6. Author(s)

Question Title

* 7. Pages to be used

Question Title

* 8. Additional Publication Information

I am requesting nonexclusive North American rights in the publication's original language to reprint the above-named PACER material as follows

Question Title

* 9. My Publication Name

Question Title

* 10. Format of Publication(e.g., book, newsletter, web page, audio)

Question Title

* 11. Purpose of Publication

Question Title

* 12. Target Audience

Question Title

* 13. Will the Project be Sold

Yes

Question Title

* 14. Subscription rate/unit price

Question Title

* 15. Estimated print run/circulation

Question Title

* 16. Estimated Publication Date

Question Title

* 17. I will cite the following credit line

Yes

Question Title

* 18. Publication Use

I am using PACER material exactly as it appears in the original publication

I would like to adapt the text of PACER material. (If so please send a copy of the material as it will appear in your publication to: Reprint Coordinator, PACER Center, Inc., 8161 Normandale Blvd., Minneapolis, MN or email to PACER@pacer.org

Please allow 10 to 15 business days for a response. If more information is needed or special arrangements are required, additional time may be needed to process your request.