PERMISSION TO USE A COPYRIGHTED WORK WHERE THE COPYRIGHT HOLDER IS UNKNOWN

___________________, of ___________________________,  is in possession of a work entitled ______________________ (“work”).  Despite  diligent efforts, the copyright  holder of the work cannot be conclusively identified. The Work is a __________________[describe type of work].    __________________ believes he/she is the copyright holder to the Work.  To the extent _________________ is the copyright holder, ________________hereby grants the University of North Carolina at Charolotte (“University”), the right to copy, distribute, and display the work, including digital reproduction and digital display on the internet.

To the extent possible,  ___________________________ represents that the Work does not infringe the copyright or other legal rights of any third parties.  If known, the Work was copyrighted in the year __    .   If unknown, the Work was created in __________.

            TERMS:

1. The University may copy/reprint, including digital reproduction and digital display on the internet or otherwise the Work, and distribute and display it for use in _____________________  in accordance with the mission of the University.

2.  Copies of the Work will not be sold or supplied.  Requests for copies  will be referred to _______________.

3.  This permission is non-exclusive, royalty-free (no cost to the University), world-wide, and perpetual.

All copies and displays of the Work by the University must credit _______________ as the creator of the Work, and must include full copyright information, if possible.  Please indicate the form of attribution preferred.

If there are any other entities with a copyright interest in this work, please provide complete contact information.

Agreed to By:

Copyright Owner signature:  _______________________________            Date:            ___ 

Printed Name:  ________________________________