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\begin{document}
    \pagestyle{empty}
  \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 the course identified below 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.

  \[
  \begin{array}{l}
    \\ \\ \\
    \begin{tabular}{llll}
      Course Number:    & \underline{\hspace{20ex}}  \\ \\
      Course Title:     & \multicolumn{3}{l}{\underline{\hspace{80ex}}}
                          \\ \\ \\
      Term (cicle one): & Fall / Winter / Summer     &
      Year:             & \underline{\hspace{20ex}}  \\ 
    \end{tabular}
    \\ \\ \\ \\

    \left .
    \begin{tabular}{ll}
     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}}
    \end{tabular}
    \\ \\ \\
  \end{array}
  \]

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