Survey - Request to reproduce copyrighted materials - Heart and Stroke Foundation of Canada / Fondation des maladies du coeur et de l'AVC du Canada

Request to reproduce copyrighted materials

	1. Name and address of individual/group making the request for permission to copy.
*	Question - Required - Name:
*	Question - Required - Contact title:
	Question - Not Required - Organization:
*	Question - Required - Address:
*	Question - Required - Province:
*	Question - Required - Postal code:
	Question - Not Required - Telephone:
	Question - Not Required - Fax:
*	Question - Required - Email:
	* Fields with an asterisk require an answer.
	2. Please describe the Heart & Stroke material you wish to reproduced (include URL if available).
	Question - Not Required - Title of Heart & Stroke Resource:
	Question - Not Required - URL:
	Question - Not Required - Pages:
	Question - Not Required - Figure/Table Number(s):
	Question - Not Required - Type of Resource: Brochure Book Booklet Cookbook Tear Sheet Video Other
	3. Please describe how the material will be used.
	Question - Not Required - placeholder question text (Maximum response 1,000 characters)
	Question - Not Required - Target Audience:
	Question - Not Required - Production Date:
	4. Source of other information in the resource
	Question - Not Required - placeholder question text (Maximum response 1,000 characters)
	5. Please provide other details on the material being produced.
	Question - Not Required - Number of copies to be produced.
	Question - Not Required - Will material be sold? Yes No
	Question - Not Required - Suggested Price:
	Question - Not Required - Will you be realizing a profit? Yes No
	Question - Not Required - Where will it be circulated/sold (countries, special markets, etc.) (Maximum response 1,000 characters)