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Please print your full name, write in the instructor and course information, and check one of the following boxes. Then sign and date the completed statement. Write in ink.

I, ______________________________________ certify that the materials in this Autobiography in Logic booklet are my original work, which was completed for Professor __________________’s course on _______________________________ (course name/number) in the  ____________ term of the year 20___. I have checked a box below to indicate how my work may be used:

◊  I give permission for the instructor to use my work in this booklet in future classes or conferences, with attribution of the work to me by name. I understand that s/he would only use it as a good example or to demonstrate various ways of completing the assignment correctly, not as an example of errors.

◊  I give permission for the instructor to use my work in this booklet in future classes or conferences anonymously, without attribution of the work to me by name. I understand that s/he would only use it as a good example or to demonstrate various ways of completing the assignment correctly, not as an example of errors.

◊  I do not give permission for the instructor to use my work in this booklet as an example in future classes or conferences.

Signature:  _______________________________________           Date:  ___________________