Publication Permission Form, Society for Creative Anachronism, Inc.

This form may be completed and e-mailed to an SCA publication for immediate use. However, if you use this on-line form, it is in trust that you will be forwarding a SIGNED form to the publication. SCA publications must have your signature on file to use your material.

I, ________________________ being known within the Society for Creative Anachronism as ________________________________ do hereby grant permission for the (Circle appropriate item(s): article/poem/picture/song/other (_____________ ) entitled: ________________________ to be used as follows (check all that apply, complete blanks where necessary):
Ownership by the publication titled and all copyright granted to that publication (Society for Creative Anachronism, Inc.), which shall determine all future use of the item named above. (Check no other item.)

 One-time publication in an issue of: Carved in Granite
 or: publication that publication no more than ____ times (separate issues).

If I have checked the last three option, I retain all copyright in my work and may grant permission to any other publication or entity to use my work.

I further certify that I am the sole creator of this work, and have not substantially based it upon the work of any other person. If others have contributed to this work or if I have based this upon the work of any person, their names and addresses (or other contact information) are:  _______________________
_______________________________________________________

Date: ________________
Signature: ____________________________________________ 
Address: ______________________________________________