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Obligatory *

Title

First Name *

Last Name *

Institute/Company *

Address

Post/Zip Code

City *

State/Territory

Country *

Telephone *

E-mail *

Information about the Elsevier publication you would like to use material from:

Journal *

ISSN *

Volume *

Issue *

Year *

Pages *

Article Title *

Author *

If using figures, tables, illustrations or video clips, please specify which ones: *

If using excerpts please provide a total word count:

Are you the author of the Elsevier material? *

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If not, is the Elsevier author involved with your project? *

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If selected above 'Yes', please provide details of how the Elsevier author is involved

In what format will you use the material? *

Printed Electronic Printed and electronic

Will you be translating the material? *

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If yes, please specify the languages:

Reuse in a book/textbook:

Reuse in a journal/magazine:

Reuse in a presentation/slide kit:

Reuse in a promotional materials/pamphlet:

Reuse in a thesis/CME Material

Reuse in a course pack/classroom material

Reuse in a CD-Rom/DVD

Reuse in a newspaper/newsletter

Make photocopies

Reuse in a conference proceedings

Reuse in a government report:

Reuse in training materials

Post on a website

Reuse in a poster

Reuse in a TV programme/documentary/movie

Reuse in a mobile application

OTHER

Reuse in a book/textbook:

Please provide the following information; intended publisher, title and author(s) of new work

Reuse in a journal/magazine:

Please provide the following information; intended publisher, title and author(s) of new work

Reuse in a presentation/slide kit:

Please provide the following information; Name of sponsor or company providing funding, number of copies to be distributed or number of meeting attendees

Reuse in a promotional materials/pamphlet:

Please provide the following information; Name of sponsor or company providing funding, number of copies or number of meeting attendees

Reuse in a thesis/CME Material

Please provide the following information: if applicable, details of your institute posting policy (e.g. posting in a repository)

Reuse in a course pack/classroom material

Please provide the following information; number of students, confirm if your institute holds a subscription if requesting to use material from a journal

Reuse in a CD-Rom/DVD

Please provide the following information; Title of your product, number of copies to be distributed, confirm if copies will be distributed free of charge

Reuse in a newspaper/newsletter

Please provide the following information; name of publisher, title of publication, number of copies to be circulated

Make photocopies

Please provide the following information; Number of copies to be distributed and for what purpose; confirm if copies will be distributed free of charge

Reuse in a conference proceedings

Please provide the following information; name of publisher, title of the conference proceedings, number of copies to be circulated

Reuse in a government report:

Please provide the following information; name of publisher, title of the report, number of copies to be circulated

Reuse in training materials

Please provide the following information; course title, number of copies to be distributed, number of course attendees, confirm if copies will be distributed free of charge

Post on a website

Please provide the following information; website address, duration of posting, confirm if the website is password protected/restricted access

Reuse in a poster

Please provide the following information; where it will be presented and number of copies to be distributed

Reuse in a TV programme/documentary/movie

Please provide the following information; title of programme/documentary/movie, context in which the requested material will be used, when and where it will be broadcasted

Reuse in a mobile application

Please provide the following information; title of application, description of product, attended target market, confirm if the application will be made available free of charge

OTHER

Please provide a description of how you propose to use the material