THIS CONSENT FORM covers the performance described below.

 Date of Presentation:
 Presenter:
 Introducer:
 Series:
 Place:
 Title/Topic:
 Length:
 Remarks:

As copyright holder for ________________________ I grant permission to Washington University Department of Special Collections to present full text and audio and/or video of the following specific selection(s) on their Modern Literature web site:
 
 

All intellectual rights in and to the material described herein shall remain the sole property of the copyright holder, and the permissions granted herein are limited to those described above.

COPYRIGHT HOLDER
By: ___________________________________Dated: ___________________
________________________________________________________________
Address, City, State, Zip Code and Telephone
 
WASHINGTON UNIVERSITY
By: ___________________________________Dated: ___________________
Title: _______________________________________