Permission Request

First Name First Name is required.

Last Name Last Name is required.

Organization Organization is required.

Identify the entity type, for example, “LLC,” “Non-profit,” “Ltd.” etc Entity type is required.

Title Title is required.

Name of Individual Authorized to Sign Permission Form (Signatory) Signatory is required.

Title of Individual Authorized to Sign Permission Form Signatory Title is required.

Address 1 Address is required.

Address 2

City City is required.

ZIP Code ZIP code is required. Please enter valid ZIP code (e.g. 10001).

Phone Please enter phone number in the following format: 5555555555 Phone is required. Please enter valid Phone Number (e.g. 3334445555)

Fax Please enter fax number in the following format: 5555555555 Please enter valid Fax number (e.g. 5556667777)

Signatory E-mail Address Signatory Email Address is required. Please enter valid email address.

Description of Material & Purpose of Use Describe the requested material in detail and the purpose of use Material and Purpose of Use is required.

Description of Manner of Use Provide details on the manner/form, expected length, location and/or medium of use. Include details such as the full title, edition, publication issue, description of publication, website, video, or other media, as applicable.

Name of Contact at GSUSA Name of the Contact is required.

Date Permission Required Please enter Date in this format: MM/DD/YYYY Permission Date is required. Please enter valid Date of Permission Required.