Name: _______________________________________

Title of Video: ________________________________

Affiliation: ___________________________________

Address: _____________________________________

_____________________________________

_____________________________________

To whom it may concern:

I have submitted the above-titled video for use by the Linguistic Society of America Video Archive.

I am the author of and owner of the rights in this work. The LSA Video Archive committee has my permission to digitize and edit this video, and to publish it on a public-domain web site. Nothing in this letter should be construed as giving up copyright of the video to the LSA Video Archive committee or any of its members. I agree to allow the Archive Director to keep one copy of this video on tape or disk, for purposes of any later website technology upgrades. I understand that this copy will be kept in a secure storage area, and will not be distributed or used for other purposes.

Signed: _____________________________________

Date: ___________________