Please provide the following information:
Full URL of Article:		____________________________________________________________
Title of Article:		____________________________________________________________
Medium (Check all that apply):		Print __________          Intranet __________          (Fee: $100 each)
		Print License: one time use up to 100 copies | Intranet License: 30-day use
		For longer term use or special circumstances, contact a Sales Representative
Intended Use (Be specific):		____________________________________________________________
		____________________________________________________________
		____________________________________________________________
Person Making Request:		____________________________________________________________
Email Address:		____________________________________________________________
Phone Number:		____________________________________________________________
Company/Institution:		____________________________________________________________
Address:		____________________________________________________________
City/State/Zip:		____________________________________________________________
Total:		$__________
Please make checks, drawn on U.S. Banks only, payable to CTQ Media - [Insert Name of Web Site].
To pay by credit card, please provide the following information:
Visa, Mastercard and American Express accepted.
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Card Number:		____________________________________________________________
Expiration Date:		____________________________________________________________
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Mail this form to:
CTQ Media Copyright Requests
321 High School Road NE, PMB 434
Bainbridge Island, WA 98110
Or fax this form to: (206) 774-6423