Permissions Request Form Organization InformationIs 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 AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 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: © 2019 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. Our mailing address is 2702 Forest Avenue, Des Moines, IA 50311.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. PhoneThis field is for validation purposes and should be left unchanged.