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\begin{document}
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  \begin{center}
    \Large
 
    Permission to Use Copies of a Student's Assignments
  \end{center}

     I hereby give permission for James Blustein to use a copy of my
   assignments from Computer Science course number~6606 (entitled Human
   Factors in On-Line Information Systems) in the Fall term of
   20\underline{\hspace{3ex}}\,\underline{\hspace{3ex}} at Dalhousie
   University as an example for other students in future courses.

     This permission does not change the ownership of any assignment.

     I acknowledge that I grant this permission entirely of my own
   volition.

     I have not and will not get any course credit or payment either by
   granting or not granting this permission.

     James Blustein acknowledges that I may rescind my permission in
   writing at any time.

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     Name:                 & \underline{\hspace{50ex}} \\\\\\
     Signature:            & \underline{\hspace{50ex}}
     \\ \\ \\ \\

     Name of Witness:      & \underline{\hspace{50ex}} \\\\\\
     Signature of Witness: & \underline{\hspace{50ex}} 
    \end{tabular}
    \right \} \mbox{Date:\,} \underline{\hspace{20ex}}
     \\ \\ \\ \\

    \begin{tabular}{ll}
     Signature of James Blustein: & \underline{\hspace{50ex}}  \\\\

     Date:                        & \underline{\hspace{30ex}}
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    \\ \\ \\
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