MGM University of Health Sciences

Contact Details

1.Title*

First Name*

Family Name*

2.Organization/affiliation*

3.Website Address

4.Type of organization*

5.Position

6.Telephone*

7.Address*

8.Country*

9.Email*

Information About Use of Material to be Used

10.Full title of material requested *

11.Please select the item(s) to be used *

12.Purpose of use *

Note:To make multiple selections, press the "Ctrl key" and click on the items to choose.

Information about the use

13.Please provide detailed information on where MGMIHS material will be used *

14.Publishing format *

15.Will you be translating? *

Yes No

16.How are you planning to use your material ? *

17.What is your planned publication or distribution date? *

18.Are you selling your material? *

Yes No

19.Duration for which use of tool is requested:

From:

to:

20.Will the data from your study be
submitted to any regulatory body
such as the CTRI etc? *

Yes No

21.How will the Copyrighted
Work be administered? *

Electronically Paper Copy

22.Which language versions will you need? *

23.Number of patients to be administered the copyrighted work(s)*

24.Number of sites to administer
the copyrighted
works *

25.How did you hear about the measure you wish to license? *

Clinical Trial Protocol
Marketing Website (Please specify in box below)
Colleague/ Referral/Word of Mouth
Publication
Previously Licensed
Research & Innovation Website
Web Search (Google, Bing, etc.)
Email
Other (Please specify in box below)

26.Is the material sponsored or funded by an organization other than your own? *

Yes No

27.Will there be any advertising associated with the material? *

Yes No

28.Additional information about your request
Number of copies of your publication (if applicable)
Url where the material will be published (if applicable)

Terms and Conditions:

This is a form to request permission and does not grant you a license to use the materials requested.
- You do not have authorization to use the materials requested unless and until your request has been approved by MGMIHS. You will receive a notification by email from the copyright team confirming or declining your request.
- If you are granted permission it will be pursuant to these terms and conditions. Please click in the box to confirm that you have read and understood the terms and conditions.
I, hereby declare, that the tool shared by MGMIHS will be used by me only for the purpose mentioned above. I understand that the tool is not to be shared with other researchers, clinicians students and professionals. The tool will not be used for any profit-making activity. I will ensure that MGMIHS will be acknowledged in any publication arising from use of tool

By submitting this request you confirm that you will abide by the terms and conditions if MGMIHS grants you permission. *
I have read and agree with the terms and conditions