FORM C 1

REQUEST FOR PERMISSION TO USE COPYRIGHTED MATERIAL

Photocopying or republishing MMU copyrighted material in another work, in whole or part, without written permission is strictly prohibited. Please note that all requests for permission must be in writing using this form. IPMC grants permission for one-time use only. New requests are required for subsequent editions, for reprints or excerpts, or for other uses of the material.

PART A (To be completed by the user)

1. / Name of Material:
2. / Particulars of User
Name / Department / NRIC & Nationality / Address / Email & Contact
(Please use a separate sheet if more than 4 users)
3. / Type of Material :
a. Computer software and manual  / b. Database  / c. Courseware/Exam material 
(intended for use outside MMU)
d. Other material  Please specify: ______
4. / Description of Material:
5. / Intended Use
A. Seek permission to:
 Reproduce the material "as is" in its entirety
 Use for research purposes
 Reproduce the material "as is" in part:
(Provide specific information such as page numbers, figure numbers, function name, function line, module, etc to identify the parts of the material you want to use).
 Create derivative work using the material (e.g., a software tool): (Please describe the derivative work)
 Use for other purpose (Please describe.)
B. Intend to use the material in:
 Book or article
- Working title
- Publication date
- Publisher
 Technical report /  Press release
 Web page / MMLS /  Presentation or briefing
 CD-ROM product /  Marketing literature
 Merchandise (e.g., T-shirt, badge, pen)
 System (e.g., software) / (Please describe)
 Other use / (Please describe)
C. Period of use:
Period of Usage: Years / Months / From: DD – MM – YYYY to : DD – MM – YYYY
D. Purpose of use:
 Commercial Development /  Non-commercial Development / Research and Development
E. Extent of use of the material:
a. Extension without modification  / b. Extension with modification 
c. Modification 
F. Intend to distribute the finished product:
 Within MMU (internal use) /  Outside MMU (external use)  Both
G. Additional Information (Please provide any additional information.)

DECLARATION BY STAFF

*I/We, the undersigned being *an employee/employees or contractors of Multimedia University declare that:

  1. The above information are true and not infringing on any rights of any third party;
  2. The above invention has been conceived in the course of *my/our *employment/contract with Multimedia University;
  3. I/We will inform Collaborative Research and Innovation Centre (CRIC) through Dean / Director of any new intellectual property derived from the material; and
  4. I/We will follow and obey MMU IP Policy and other related policies.
  5. Should there be any commercial exploitation arising from this disclosure, I shall make full and frank declaration to CRIC on any income(revenue/royalty/etc) generated.

Date:
Name and Signature:

PART B (To be completed by Dean/Director)

1. / Received on:
2. / Recommendation for "intent to use copyrighted material" application: / Yes / No
3. / Remarks:
4. / Date:
5. / Name & Signature of Dean/Director:

PART C (To be completed by Collaborative Research and Innovation Centre)

1. / Received on:
2. / Date:
3. / Name & Signature of Director of CRIC

PART D (To be completed by IPMC)

1. / Received on:
2. / Approval for "intent to use copyrighted material" application: / Yes / No
3. / Remarks:
4. / Date:
5. / Name & Signature:

*Delete where applicable

Tick [] in the appropriate box

Notes:
a) This form must be completed and submit to IPMC through CRIC:
to Collaborative Research and Innovation Centre, 2nd Floor, The Chancellery Building, Multimedia University, Jalan Multimedia, 63100 Cyberjaya, Selangor Darul Ehsan, Malaysia.
b) An incomplete form shall be rejected and returned to the requester.
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