REQUEST FOR PERMISSION TO REPRINTOA COPYRIGHTED MATERIAL

Please complete and sign this request form and mail, fax or email the signed form to the World Service Officeof Overeaters Anonymous. Permission is effective only when the form is signed by Overeaters Anonymous,Inc. and returned to the applicant.

Date:________________

Permission is requested by the undersigned applicant to:

a) Reprint the following material from the Overeaters Anonymous publication entitled:

The excerpted material is (give page numbers, where pertinent):

b). Use the excerpted material as shown in the manuscript submitted with this form (enclose a complete copyof the work in which the excerpted material is used).

The excerpted material will be used in a volume (herein called the “volume”) entitled:

by: __________________________________________________________________________________to be published, i.e., placed on sale, sold or publicly distributed by ________________________________

______________________________________________________________________________________no later than _________________________________________ (publication date)

World Service OfficeP.O. Box 44020

Rio Rancho, NM 87174-4020 USATel: 1-505-891-2664 Fax: 1-505-891-4320

www.oa.org

The applicant agrees:

1. Except as herein provided, to make no adaptation or changes in the excerpted material without the priorwritten consent of Overeaters Anonymous, Inc.

2. To use the excerpted material only in the above mentioned edition of the volume.3. To print the credit as given below on the copyright page of the volume or on the page or pages on which the

excerpted material begins.4. To send one copy of the volume to Overeaters Anonymous, Inc., on or before publication.5. That permission will terminate if the volume is not published within two years from the date of this request

and shall in any event terminate within ten years from the date of this request.6. We understand and agree that OVEREATERS ANONYMOUS, INC., may terminate the permission at any

time upon thirty (30) days notice without cause and immediately if we fail to comply with any term or con-dition hereof. Upon termination of the permission, we shall immediately discontinue further printing of thevolume. However, we shall have an additional period of two (2) years from the time the permission termi-nates within which to dispose of any copies of the volume that we printed prior to such expiration unlessthe termination of permission is caused by our violation of any provisions of this permission, in whichevent, we shall be prohibited from disposing of any additional copies of the volume.

7. We understand that this agreement will be governed and construed under the laws of the State of NewMexico and the United States of America, and we consent to the jurisdiction of the State and Federal Courtlocated in the State of New Mexico USA, and waive any defense to any such jurisdiction.

Signature of applicant: ______________________________________________________________________Print applicant’s name: ______________________________________________________________________Service body (if applicable)____________________________________________________________________Address: __________________________________________________________________________________

__________________________________________________________________________________Phone/Fax ________________________________________________________________________________E-mail: ____________________________________________________________________________________

PERMISSION GRANTEDPermission is hereby granted to reprint the above described excerpted material on the above terms and condi-tions and on the condition that the applicant give the following form of credit:

OVEREATERS ANONYMOUS®, INC.

By: ____________________________________________________ _____________________________Managing Director/ Corporate Secretary Date

From: ___________________________________________________________________ (Name of publication)

Copyright 19/20___ by Overeaters Anonymous, Inc.Reprinted by permission of Overeaters Anonymous, Inc.

CREDIT LINE

Revised 4/14