Please complete the following form to request permission to use Intermountain materials.

  • Requests are processed in the order they are received.

Requester Information
Insert the legal name of the organization or individual making the request.
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Type of business

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Describe the requestor’s line of business.
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Insert the requestor’s street address.
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Insert the requestor’s city.
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Insert the requestor’s state.
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Insert the requestor’s zip code.
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Insert the contact person’s name.
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Insert the contact person’s position.
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Insert the contact person’s email address.
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Insert the contact person’s phone number.
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Request Details
Insert the request date.
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Provide the title to and a description of the requested materials. If the requested materials are available online, please provide a link. If not, please provide a copy of the requested materials with your completed request form.
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Requested Use - Please fill in all fields which apply to you. Not all fields are required.
Internal (staff and patients) or an external audience.
Describe the proposed distribution, including the intended audience and location.
Enter proposed charge.
If the publication is a journal, enter the name of the journal and the name of the article. If the publication is a book, enter the name of the book and the applicable chapter.
Describe the proposed display or performance, including the intended audience, location, and date.
Describe the changes or portion you wish to make/use.
Describe the content into which you wish to integrate the materials.