USABP

United States Association for Body Psychotherapy

PMB 294

7831 Woodmont Avenue

Bethesda, MD 20814

E-Mail: admin@usabp.org

Print or email this form. Please provide complete information. Your request will be reviewed, and a response will be sent to you as soon as possible.

I request permission to copy the listed material for the following use (see below):

Requested By:

____________________________________

Company:

____________________________________

Address:

____________________________________

Telephone:

____________________________________

Fax:

____________________________________

ARE YOU A USABP MEMBER?

O - YES Member No. ______________________________

O - NO

Material to be used:

O - Photo/Illustration

O - Article

O - Other (specify) __________________________________

Publication (Title, Vol., No., Pg.):

________________________

Article Title:

________________________

Pages:

________________________

No. of Copies & Copying Method:

________________________

Proposed Use of Copyright Material (please give detailed description):

_________________________________________________

Legal Notices & Disclaimer | Privacy Policy | Copyright Request | Linking Policy

© 2003-2009 United States Association for Body Psychotherapy,
8639 B 16th St., Suite 119, Silver Spring, MD 20910
All rights reserved. usabp.org® is a registered trademark of the United States Association for Body Psychotherapy®

No part of this Web site may be reproduced, stored in a retrieval system, or transmitted in any form by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the United States Association for Body Psychotherapy.