Pennsylvania Institute for Instructional Coaching (PIIC) Permission Request Form
Please use this form to request the use of documents from all PIIC-affiliated websites (www.pacoaching.org and www.instituteforinstructionalcoaching.org). Please allow five business days for the permission request to be reviewed.

Please note PIIC cannot grant permission for documents that do no belong to PIIC. Anyone who requests use for documents that do not belong to PIIC will be directed to contact the owner of said document.

First Name *
Your answer
Last Name *
Your answer
E-Mail Address *
Your answer
Title *
Your answer
School District/Organization *
Your answer
Address *
Your answer
City *
Your answer
Zip/Postal Code *
Your answer
State/Province *
Country *
Your answer
Phone Number *
Your answer
Fax Number
Your answer
Work requested is a: *
Name of the Document, PowerPoint, or Video: *
Your answer
From which PIIC website was the document, PowerPoint, or video first viewed? *
Where will the requested piece be used? *
Please list locations (City, State/Province, Country) where the material will be used: *
Your answer
If applicable, please provide the estimated reprint or distribution amount: *
Type of Rights (check all that apply) *
Required
If document is used in an electronic format, will access to the information be restricted and password protected?
Please provide the website address if used in an electronic form:
Your answer
Please describe how you intend to use the material: *
Your answer
Credit Agreement *
Required
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