Copyright & Content Permissions Inquiry Form Permission RequestName(Required) First Last Email Address(Required) Organization / Affiliation(Required)Title(Required)Phone(Required)Type of Permission You Are RequestingPlease select the primary category that best describes the intended use:(Required) Clinical Trial Use Academic Use (research, coursework, theses, presentations) Publication Use (journals, books, scientific articles) Commercial Use Translation / Localization Media or Communications Use (videos, presentations, podcasts, websites) Internal Organizational Use Other Please describe the nature of your request.(Required)Identify the MGFA Material You Wish to UseTitle or Description of the Material(Required)If quoting a specific section, include the exact text.Citation or Link to the MGFA Material(Required)URL or reference informationHow do you plan to post or distribute the material? (select all that apply)(Required) Brochure Website Page Presentation Slide(s) Image/Graphic Video/Audio Assessment Tool / Classification / Scale Other (please specify) Other – MGFA Material You Wish to Use(Required)Other – MGFA Material You Wish to UseUpload any files or excerpts relevant to your request (optional) Drop files here or Select files Max. file size: 100 MB. Intended Use DetailsPlease describe exactly how the material will be used.(Required)Include where, when, and for what audience the content will be shared or published.Will the material be reproduced or distributed? Will the material be reproduced or distributed? Estimated distribution size or reach(Required)Will any fees be charged for access, participation, or distribution of the work containing MGFA content? Will any fees be charged for access, participation, or distribution of the work containing MGFA content? Please explain the fees(Required)Is this request for website use? Is this request for website use? Please provide the URL of the website(Required)Rights VerificationTo your knowledge, does your organization hold any existing rights or agreements related to this material?(Required) Yes No Unsure If Yes or Unsure → Please provide details or upload documentation(Required)Are redline changes needed for the agreement? Are redline changes needed for the agreement? Terms & Conditions + Digital SignatureBelow is a condensed version of the MGFA Copyright/Content Permissions statement.(Required)Terms Summary: • Permission is non-exclusive, non-assignable, and royalty-free. • MGFA retains all rights under copyright, trademark, and other applicable laws. • Approved use must match the description provided in this request. • Any additional or future use requires a new request. • You agree to provide full and accurate citation to MGFA as instructed. I have read and agree to the terms above and confirm that all information provided is accurate.Legal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. Paper Copies You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies. Withdrawal of Consent You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below. Withdrawing your consent, requesting a paper copy, or updating your contact information You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices. “Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address. “Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy . “Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number. The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.Requester Name(Required) First Last Requester Signature Date MM slash DD slash YYYY Requester Signature(Required)MGFA USE ONLYMGFA Signature Name First Last MGFA Signature Date MM slash DD slash YYYY MGFA Signature Waiting for another signer Submission & Next StepsUpon submission, your request will be routed to the appropriate MGFA team for review. Typical response time is 5–10 business days depending on the nature and complexity of the request.
