ALTA Permission to Reprint Request Form V.3 08-24-2017

Page 1 of 2

For Internal Use Only:

Permission to Reprint granted denied

Payment received Yes No

Permission to Reprint Request Form

Applicant’s Name: ____________________________________________________

ALTA ID (if known): ____________________________________________________

Organization: ____________________________________________________

Address: ____________________________________________________

Phone: ____________________________________________________

Email: ____________________________________________________

ALTA Member: Yes No

This request is: a new request a renewed request

ALTA Material Requested:

Title of Material: __________________________________________________________

Source of Material (e.g., electronic, printed source, etc.): __________________________

Publication Date: _______________________

URL (if applicable): ________________________________________________________

Information about the Work in which the ALTA Material will Appear:

Author/Editor/Publisher: ___________________________________________________

Type of Publication: Presentation Reprint on Website Print Publication

Publication is available for: Free a Fee of $_______________

Title of Publication: ________________________________________________________

Projected Date of Publication: _______________________________________________

Purpose of Publication (i.e., educational, commercial, etc.): ________________________

Continued on following page

ALTA Permission to Reprint Request Form V.3 08-24-2017

Page 2 of 2

The American Land Title Association (ALTA) authorizes reprint of copyrighted ALTA materials upon consideration of a completed Permission to Reprint Request Form and receipt of the $50 application fee, if applicable. ALTA members, government employees, and educational institutions are exempt from paying an application fee. All other Applicants must submit a $50 application fee to accompany this form in order to be granted permission to reprint. A renewed reprint request may be submitted if the Applicant has previously applied for a request to reprint material and plans to use that material in a work not listed on the initial application (e.g., publish ALTA material in a subsequent volume or edition of a work). Renewed requests are subject to the same application fees as new requests. ALTA reserves the right to deny permission to reprint at its sole discretion. If permission to reprint ALTA material is granted, Applicant agrees to cite the title and source of the ALTA material and include the below:

“Reprinted with permission from the American Land Title Association (ALTA). ALTA reserves all rights.”

Applicant acknowledges that the permission to reprint is limited to the specific use set forth on this application.

Applicant’s Signature: __________________________ Date: ______________________

Complete Billing Info:

Card Number: _____________________________________________________ CVV: _________________________ Expiration Date: _________________________ (MM/YYYY) Name on Card: _____________________________________________________ Billing Address: _____________________________________________________ Billing City, ST Zip: _____________________________________________________ Cardholder Signature: _____________________________________________________