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Permission Request Form

This form is for use by all third parties (Licensee) seeking permission from Girl Scouts of the USA ("GSUSA") to [check all that apply]:

First Name: *  
Last Name: *  
Organization: *  
Title: *  
Name of Individual Authorized to Sign Permission Form (Signatory): *  
Title of Individual Authorized to Sign Permission Form: *  
Address 1: *  
Address 2:  
City: *  
Zip Code: * (US Only)  
Country: *  
State: * (US Only)  
Phone Number: *  
Fax Number:  
Signatory E-mail Address: *  
Description of Material: *
(max: 2000 characters)
  Describe in detail the material(s) for which you request permission to reprint:

Description of Manner of Use: *
(max: 2000 characters)
  Describe in detail the manner in which the Material(s) will be used, including, e.g., full title, edition and description of publication, website, video or other media
Name of contact at GSUSA: *  
Date permission required:*  
* Indicates required field.