<p>Date</p><p>{Company name} {contact person} {address}</p><p>Permission To Reprint</p><p>In consideration of publication with the appropriate credit line, I Carolyn Moffatt hereby give {name/address}, its successors and assigns, and those acting under its permission or upon its authority, the right and permission to reproduce, publish, circulate, otherwise use the work described below. This permission also encompasses electronic distribution of the work. I warrant that I own all legal rights and copyrights to the work. I further warrant I have full authority to enter into this agreement. The terms of the agreement shall be binding on both the copyright holder.</p><p>Name of copyright holder: American Spinal Injury Association</p><p>Title of Work: {title of publication/use of chart}</p><p>The dermatome chart that is contained in the ASIA publication. “International Standard for Neurological Classification of Spinal Cord Injury” may be freely copied, but not changed in any way without prior permission from the American Spinal Injury Association.</p><p>Credit Line to appear as follows: ASIA requires that a citation of the source be included, however. We suggest the following: “American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA, Revised 2011, Updated 2015</p><p>Carolyn Moffatt Association Manager</p><p>2209 Dickens Road ● Richmond, VA 23230-2005 USA ● Main (804) 282-6396 ● Fax (804) 282-0090</p>