Application for Copyright Clearance on Public Health Agency of Canada Works

The material on the Public Health Agency of Canada website is covered by the provisions of the Copyright Act, by Canadian laws, policies, regulations and international agreements. Such provisions serve to identify the information source and, in specific instances, to prohibit reproduction of materials without written permission.

To submit your request for copyright permission, please complete the following form. The personal information you provide is collected to allow Public Health Agency of Canada to evaluate your request and to inform you of the decision. This personal information is protected under the Federal Privacy Act. Accordingly, it will be used, retained and disclosed for the purpose mentioned above only. Learn more about our commitment to privacy.

Please note that this form applies to Public Health Agency of Canada works only, and that all fields marked by an asterisk (*) must be completed.

1. Applicant Information

Name (required)

Organization (if applicable)

Postal Address (required)

City (required)

Province/State (required)

Postal/Zip Code (required)

Country (required)

Telephone No. (required)

Facsimile No.

E-mail Address (required)

Web Site Address (if applicable)

If permission is granted, person/organization in whose name permission is to be issued (required)

Individual named above

Organization named above

Other

Other (please specify):

2. Information on the applicant's work

Purpose (required)

Reproduction

Adaptation

Revision

Translation

If Translation, specify the language of your work.

N.B. If the material has been adapted or revised, copies of your adapted/revised work and Public Health Agency of Canada's material must be included with your request.

Format(s) in which your work will be produced(required)

Paper

Internet

CD-ROM

Video/Film

Audio Diskette

DVD

Other

Other (please specify):

Number of copies to be printed / produced OR Specific URL(s) for web page(s) where your work will be published:

End Use (required)

Commercial

Non-Commercial

Educational

Free Distribution

Advertising/Promotion

Other:

Other (please specify):

Commercial sale price or price for works produced on a cost-recovery basis

Territory where your work will be distributed (required)

Canada

World-wide

Other

Other (please specify):

3. Response

I would appreciate receiving a response by: (YYYY-MM-DD)

4. Other

Have you previously received approval to use the same material(s)?

Yes

If yes, previous approval date. (if available) (YYYY-MM-DD)

5. Information on the Work

Title: (required)

Year/Date of publication: (YYYY-MM-DD)

Format of Source Material (required)

Paper

Internet

CD-ROM

Video/Film

Audio Diskette

DVD

Other

Other (please specify):

Reference Numbers

ISBN or ISSN:

Catalogue Number:

Publication Number:

OR Exact URL where source material is published:

Precise description of material to be used

Volume/Issue:

Page No(s):

Table No./Figure No.:

Image/Photo No./Description:

Additional Information

6. Applicant's Reference No.

(If you wish to assign one)

Page details

2026-07-24

Language selection

Search

Application for Copyright Clearance on Public Health Agency of Canada Works

1. Applicant Information

2. Information on the applicant's work

3. Response

4. Other

5. Information on the Work

Reference Numbers

Precise description of material to be used

6. Applicant's Reference No.

Page details