Permissions Request Form Organization InformationPlease read the guidelines on usage: http://www.trrfccjuly.wpengine.com/copyright/Is your organization currently a CHARACTER COUNTS! member?*YesNoIs your organization a nonprofit?*YesNoOrganization Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Website* Contact InformationContact Name* First Last Title*Email* Enter Email Confirm Email Phone*FaxCHARACTER COUNTS! affiliationName of member organization (if different)How many youth are (or will be) involved in CHARACTER COUNTS! activities at your organization?*Are you a graduate of a Character Development Seminar?*YesNoType of trainingCharacter development seminarOn-site training programPVWH seminarAt-risk management seminarYearMaterial Permission RequestBy what date do you need the permission?* Item Requested* Logo Book Product Workshop material Other Logo NameBook Name, SKU or ISBNProduct Name or SKUWorkshop Material NamePlease describe:*This field is limited to 2,000 characters.Marketing Communications* Yes. Please include me in your weekly newsletter mailing list. No. I do not wish to receive marketing emails. Intended Use1) Permission to reprint and Institute articles, logos or workshop materials is granted only for one-time use and only for purposes listed in the statement of intended use. Any additional reprints must be applied for in writing. 2) Permission does not include the right to syndicate, rent or loan. 3) If you wish to edit an article, the Institute must approve the changes before it will grant permission. You may not alter or manipulate workshop materials in any way. 4) Proper credit for reprints must be given with the following line: © 2016 Josephson Institute. Preprinted from (name of publication) with permission. www.charactercounts.org 5) One complimentary copy of the reprinted material for which permission has been given shall be furnished to Character Counts Service Corporation. Our mailing address is 3472 W. Century Blvd., Inglewood, CA 90303.Number of Impressions (if printed):Please attach a sample draft of project:PLEASE CONFIRM:* I have read and agree to all the conditions provided herein and am an authorized agent of the provided organization for this request. NameThis field is for validation purposes and should be left unchanged.