Fill and Sign the Permission to Publish Thesisdissertation Form

- 1 - Copyright 2004 USLegalforms.com 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 submit ting 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 t o 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 - 2 - 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