Date:   ___________

The undersigned contact for the named electronic meeting requests permission for its members to quote short excerpts (maximum one paragraph) from Al-Anon Conference Approved Literature during its on-line meetings in accordance with the attached guidelines and licensing letter.

Permission to use the excerpted materials is intended for use on the on-line meeting of:

Name of Meeting:   ____________________________

By (printed name of meeting contact)    ________________________

Signature of applicant   __________________________

Each on-line sharing must be accompanied by the following acknowledgment:

It is acknowledged by the meeting contact that use of excerpts is for on-line meeting purposes only. By group conscience of the on-line meeting it is agreed that excerpts may not be altered, printed or archived for later combination with other sharings or excerpts. They may not be included or published on any website or posting, may not be made available to any person or website other that at and for that particular meetings and should be treated like a personal, private communication of each participant in the meeting.

Permission is granted for one year only from the date of this form.

Al-Anon Family Group Headquarters, Inc.
1600 Corporate Landing Parkway, Virginia Beach, VA 23454-5617

By ______________________________Date _________
             Executive Director