Fill and Sign the Permission Publish Form

PERMISSION TO PUBLISH THESIS/DISSERTATION I hereby grant       permission to publish my thesis/dissertation should it be chosen for publication, and with an abstract of       words or less. The title of my thesis/dissertation and other relevant information is listed on the attached addendum. I grant the aforementioned the non-exclusive rights to reproduce and distribute my thesis/dissertation in and from digital format, electronic format or microfilm along with the non-exclusive right to reproduce and distribute my abstract in any format whether in whole or in part. I represent and warrant that the thesis/dissertation and abstract that I am submitting are my own original work and do not infringe upon or violate any rights of others and that I am the sole owner of this works. I understand that it is my sole obligation to obtain any copyright permission necessary to publish the dissertation/thesis being submitted.       Agrees Does not agree to offer copies of my thesis/dissertation for sale, and to publish an abstract of my dissertation in       . _____________________       Author’s Signature Date - 1 - Copyright 2004 USLegalforms.com ADDENDUM Author’s Information: Name:       Last First Middle Phone: (h)       (w)       (c)       Permanent mailing address:       City:       __________ State:       Zip:       Name of University conferring degree, and college, department:       Degree Awarded:       Year:       Other relevant information: Advisor and Thesis/Dissertation Information: Name of Advisor:       Title:       Title of Study:       ______________________       Advisor’s Signature Date - 2 - Copyright 2004 USLegalforms.com