Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697722248683.pdf (Canada)
Consent Form – Poem of the Month Program Parliamentary Poet Laureate I, First name Last name , whose contact information is as follows: Street address Email address City Province Postal code Telephone number Fax number hereby authorize the Library of Parliament to publish on the Parliamentary Poet Laureate’s website my poem entitled: ________________________________________________________, selected for the Poem of the Month Program.
I attest that I am the sole author of this poem, that the poem has never been published and that I have not assigned or licensed my copyright on this poem to a third party.

For the purpose of the Poem of the Month Program, I consent to my poem’s appearance on the Parliamentary Poet Laureate’s website for a minimum of two years from the date it is first posted on the site.

I retain my copyright on the poem and on its translation.
I understand that my unpublished poem is selected by the Parliamentary Poet Laureate and that only the latter is responsible for choosing the poems to be posted on the website.

At my discretion, I may accept an honorarium of $125 from the Library of Parliament.
This payment is conditional on receipt of the duly signed original of this form, accompanied by the direct deposit form, also filled out and signed, on which my social insurance number or, as the case may be, Goods and Services Tax or Harmonized Sales Tax number is indicated.

I understand that payment will be made within 30 days after my poem has been posted on the website.
I acknowledge that, if I choose to receive the honorarium of $125, it is considered income under the Income Tax Act and that the Library of Parliament will send me a T1204 form.

Page 1 of 2 Page 2 of 2 – Consent Form – Poem of the Month Program I accept the $125.

I decline the $125.

I have read and understood the terms and conditions of this consent; I understand that the Poem of the Month Program Participation Policy is an integral part of this consent and I agree to its terms and conditions.
I have enclosed my direct deposit form, and understand that no payment of honorarium will be made until the form is received at the Library, filled and signed, (no payment will be made by cheque) nor in absence of my social insurance number; I have enclosed my biography (90 words maximum).
__________________________________________ Signature of poet ______________________ Date Please print the form, fill it out and return it duly signed, accompanied by the direct deposit form, if applicable, in one of the following ways: By mail: Library of Parliament Parliamentary Poet Laureate 50 O’Connor Street Ottawa, Ontario K1A 0A9 By email (digital version): loppoet@parl.gc.ca By fax: 613-992-3611 Spending/Procurement Authority: Poet 2014 Programming / 660-55451-KCO0202-21-1-C0210 ***For internal use only*** ____________________________________________ Benoit Morin, Director _________________________ Date ______________ Amount