Application form 'Electronic publishing of a dissertation at the University of Groningen'

Name and address Surname * First name and infix   Prefix/title Work address Phone number work Private address Private phone number E-mail address * RUGnummer About the dissertation Title * Promotion date (DD-MM-YYYY) - - * ISBN printed version ISBN electronic version Did you transfer your copyright to a publisher?   Yes     No  * If so, do you have permission for making public your electronic dissertation via a repository?   Yes     No     not applicable  * If so, did you arrange with the publisher that the Library is not allowed to offer 'printing on demand' as long as the publisher keeps the dissertation in print?   Yes     No     not applicable  * Should the library place the contents of the dissertation under embargo before making it public?   Yes    No If so, how long should the embargo period be? Should the entire dissertation be under embargo or just one or more chapters? (Please specify) Which program was used to create the files? (For example Word 2003, Acrobat 5.0) Remarks