Application for Copyright Clearance of Canada Border Services Agency Material

Privacy Statement

The information you provide in this document is collected under the authority of the Financial Administration Act (FAA), and in accordance with the Communications Policy of the Government of Canada for the purposes of public requests seeking permission to reproduce Canada Border Service Agency (CBSA) materials. The information may be disclosed internally to CBSA Programs and externally to other Government institutions for the purposes of fulfilling this request.

Individuals have the right of access to and/or can make corrections to their personal information under the Privacy Act. The information collected is described within Info Source under the Public Communications Personal Information Bank PSU 914 which is detailed at http://www.cbsa-asfc.gc.ca.

Form

• Applicant Information
  • Title (Mr./Mrs./Ms.)
  • *First Name
  • *Last Name
  • *Type of Organization (Individual, business, charity, etc.)
  • *Organization
  • *Postal Address
  • *City/Town
  • *Province/State
  • *Postal/Zip Code
  • *Country
  • *Telephone number
  • Facsimile number
  • *Email address
  • Website address
  • *If permission is granted, person/organization in whose name permission is to be issued
    • Individual named above
    • Organization named above
    • Other (please specify)
• Information on the CBSA Material, for which Copyright is being Requested
  • *Title of CBSA material
  • Year/Date of Publication
  • *Format of Source Material
    • Audio CD
    • CD-ROM
    • Electronic / Internet
    • Audiocassette
    • Diskette
    • Large Print
    • Braille
    • DVD
    • Map
    • Smart phone app
    • Paper
    • Videocassette
    • Other (please specify)
  • *Reference numbers (ISBN, ISSN, Catalogue / Publication Number): OR * Exact URL where source material is published
  • Precise description of the material being requested, in whole or in part
    • Database
    • Map
    • Figure
    • Photo
    • Footage
    • Text
    • Logo
    • Whole material
    • Illustration
    • Table
    • Other (please specify)
  • Volume / Issue
  • Page No(s)
  • Table / Figure No
  • Image / Photo No. / Description
  • Other
  • *How you received/found the material (i.e. Access to Information and Privacy [ATIP])
• Information on the Applicant's Material
  • *Purpose
    • Reproduction
    • Adaptation
    • Revision
    • Translation (*specify languages of your material)
  • Will the material be revised or altered in any way? If the CBSA's material has been adapted or revised, copies of your adapted/revised material and the CBSA's material must be included with your request.
  • *Briefly describe the proposed use
  • *Title of which the CBSA material will be published under
  • *Format(s) in which your material will be produced
    • Audio CD
    • CD-ROM
    • Electronic / Internet
    • Audiocassette
    • Diskette
    • Large Print
    • Braille
    • DVD
    • Map
    • Smart phone app
    • Paper
    • Videocassette
    • Other (please specify)
  • *End Use
    • Commercial (i.e. sale)
    • Non-commercial
    • Cost-recovery
    • Promotional
  • *Sale or cost-recovery price. Include sales annually or the price per unit
  • *Number of Copies to be printed/produced
  • URL(s) for Web page(s) where the material will be published
  • Additional Information

Date modified:

2014-06-18