FROM:                                                                     DATE____________________

Name:_________________________________________________________
Address:_______________________________________________________
City:_____________________________State_________Zip______________
Telephone (_______)_____________________________

Permission is requested to reprint from the following Prevent Child Abuse America copyrighted publication:

Title:___________________________________________________________
Author(s):_______________________________________________________

Pages on which material appears or other identifying information:
(please note that an entire copyrighted publication may not be reproduced)
_______________________________________________________________
_______________________________________________________________
The reprinted material will appear in ___________________________________
_______________________________________________________________
which  is published by______________________________________________
Reprinted material will be published on (give date)_________________________
Approximately __________ copies will be printed.
Copies will be distributed to__________________________________________

*NOTE:  IF YOU ARE REQUESTING PERMISSION TO REPRINT MATERIAL IN A PERIODICAL, ENCLOSE SAMPLE ISSUE WITH THIS REQUEST.

______________________________________________________
Signature

RETURN THIS FORM TO:

Prevent Child Abuse America, Attn:  Alice Auer
200 S. Michigan Avenue, 17th Floor
Chicago, IL  60604-2404
Fax:  (312) 939-8962
Phone:  (312) 663-3520