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Permission for Use of Intellectual Property Form

I am the owner of the intellectual property cited below and I hereby grant The University of Texas at Austin a limited license under my copyright(s) to copy, display, perform, distribute and publish these works in digital form over the Internet or any successor network.

Title of work:

Description of work:



Name of Copyright Holder:
Signature:

Address of Copyright Holder:

E-mail address of Copyright Holder:
Date:
Mail this form to:
UT [Knowledge Gateway] Use Permission
Attn: [Contact Name]
The University of Texas at Austin
[Mailing Address] or
[Street Address, Room]
Austin, TX [Zip Code]

The following information will accompany digitized material for which a limited license under the owner's copyright has been granted:

"Copyright © 2003 by John Dough. [address of copyright holder provided if requested.] Presentation of this material on UT [Knowledge Gateway] by The University of Texas at Austin was made possible under a limited license grant from the author or creator who has retained all copyrights in the works."