NTCIP Request for Permission to Reprint

TO: /

NEMA via fax (703) 841-3331, Attention -- NTCIP Coordinator

1300 North 17th Street, Suite 1847
Rosslyn, VA 22209-3801
FROM: / (name)
(address)
(fax)

1. REQUEST. The undersigned hereby requests permission to excerpt and reproduce the following copyrighted material, in accordance with the terms and conditions of this agreement.

2. MATERIAL. The reproduction shall be limited to the:

NTCIP Standards Publication No. / Number, title, version or date, and description of portion of document to be excerpted, such as page range, clause(s), paragraph(s), figure or table number, or other identifying information

3. PURPOSE AND USE. The excerpted material is to appear without change in the following publication:

(author and full title)
(publisher)
(expected date of publication)
(form of publication) / Hardcopy book, Adobe® PDF file, electronic briefing, Web site page content, or other
(expected sale price)
(number of copies; other info)

4. MARKING OF REPRINT. This notice must appear on the copyright page of the publication, or on the first page containing each excerpt covered by this permission, on every copy, all in the form: "Reprinted from NTCIP [number and version and title of the publication] by permission of NEMA. Excerpt © 2002 AASHTO / ITE / NEMA [or the identical copyright notice appearing in the NTCIP publication]."

5. OTHER TERMS. This permission is non-transferable and can only be used by the requestor for the form of reproduction stated above. This agreement does not apply to subsequent amendments or substitutions for the requested material, and does not cover digest, abridgement, or selections that may be made of the publication. NEMA is willing to waive a reproduction fee for the cited material, if and only if the requesting organization's publication is NOT FOR RESALE. One copy of the requestor’s work will be forwarded upon publication to NEMA. This permission is valid for one year for Web-based publication, or until the date of the next NTCIP revision, or shall terminate seven years after the approval date.

6. AGREEMENT. If you agree with the terms and conditions, indicate your acceptance by returning a signed copy of this request to the NTCIP Coordinator, fax (703) 841-3331.

______

(authorized signature from requesting organization) (title)

______

(printed name)

7. PERMISSION. The above request is hereby approved, subject to the terms and conditions above. This request and approval contain all the terms and conditions relating to the permission to reprint.

______

(authorized signature from NEMA) (date approved)

Date coord with Communications: / Date copied to Communications:

8006 Annex C 10/02