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Bibliographic Information
	 1. Author(s) __________________________________________________

	 2. Article Title ______________________________________________

	 3. Pages, Volume and Year of Publication ______________________

Course Information
	 4. Course Name and Number______________________________________
	 5. School Name ________________________________________________
	 6. Academic year ______________________________________________
		                  (one year limit, must renew each year)

	 7. Number of copies ___________________________________________

Instructor Information
	 8. Name _______________________________________________________

	 9. Department _________________________________________________

	10. School _____________________________________________________

	11. Postal address _____________________________________________

	12. E-mail or Phone ____________________________________________

	13. In any reproduction, entries # 4-7 above, I certify to have 
		the following reprint line on the first page of the said article:
		Reprinted with permission from Academic Exchange Quarterly 
		ISSN 1096-1453, PERMISSION # _________ Date of clearance _____ 
	14. I understant that 
		A. any reproduction without ISSN 1096-1453 PERMISSION #___ will  
		   be deemed to be unauthorized and a violation of copyright 
		B. this request is made with the purpose of teaching, scholarship 
		   or research in accord with the "Fair Use" provisions of the 
		   Copyright Law, Section 107
		C. the permission granted in this copyright clearance is limited 
		   to the course and institution listed above, # 4-7, and to be 
		   used for one academic year only 
		D. said article represents copyrighted material and may only be 
		   reproduced in whole for personal or classroom use; it may not 
		   be edited, altered, or otherwise modified
		E. permission WILL NOT BE GIVEN to republish in any journal, 
		   textbook, or website UNLESS APPROVED BY THE AUTHOR(S)
		   Please contact the author of the article first. 
		   Next,  attach author's approval to this form.

	15. Sign and date here __________________________________________
			       (signature must represent the name in entry #8) 

To obtain your free copyright clearance
  1. print two copies of this form, type or write legibly
  2. supply required information, entries # 1-15
  3. enclose self-addressed-envelope
  4. send by postal mail to:
    Academic Exchange Quarterly, P.O. Box 131 Stuyvesant Falls, NY 12174
  5. We will return one copy of this form with the following authorization completed:

	Permission granted to use aforesaid article in the specified class 
	for school year ______  free of any royalty fee. PERMISSION # ___________

	Authorized signature and date _____________    VALID WITH
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June 2011