Print on Mt. SAC Letterhead

(Insert Date)

(Insert Name/Address of the Copyright Owner Attn: Permissions Department)

Dear (Insert Name of the Contact Staff in the Company’s Permissions Department):

The purpose of this letter is to request authorization to modify instructional multimedia material to include captioning for students attending public postsecondary education at Mt. San Antonio College (Mt. SAC) in Walnut, CA.

Please complete the statement that appears on the bottom portion of this correspondence and return it to:

(Insert Name, Title, Address, and Contact Information of College Staff Seeking Permissions)

This request is time sensitive and requires an immediate response. Please reply on or before (insert date which is 10 days after your request).

Title of Publication and Publishing Details: 	
Copyright/Trademark Owner: 	
Address/Contact Information for Copyright/Trademark Owner:

	
Mt. San Antonio College requests authorization to modify the multimedia material to include captioning for the purpose of ensuring access for students with disabilities within the instructional setting for education purposes. The material is used in conjunction with classroom instruction for educational purposes. The multimedia material will be used until such time the material is removed from the Mt. SAC collection (unless the Copyright/Trademark Owner specifies an expiration date).

Your signature on this document confirms that permission has been authorized. This authorization will be clearly placed on the audiovisual material, along with the date that permission was authorized.

Permissions Department Authorization	Date

(Printed Name, Title, and Company of Individual Granting Authorization