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Updated 14 March 2017

Please ensure that all 3 sections of this form are completed and signed before emailing to the
Postgraduate Office (

Family name:

Other names:

Student ID number:

Permanent email address:

Senior Supervisor

Thesis Title


Course of Study (e.g., PHIL790)

Has an embargo of the thesis been Yes No

applied for? If yes for how long? months

 I declare that the thesis submitted is my own original work. yes
 I declare that the thesis contains research reported in co-authored work that has been published,
accepted for publication, or submitted for publication. no yes
If yes, I confirm that a copy of the co-authorship form has been included for each co-
authored work included in the thesis. yes
 I declare that where necessary I have obtained the appropriate copyright permission for
any material from the thesis that has previously been published (e.g., for a journal) for its
inclusion in the thesis and for it to be made made openly accessible in an appropriate
repository through the UC Library. yes
 I declare that the thesis does not contain material previously published or written by a
third party, except where this is appropriately cited through full and accurate referencing. yes
 I declare that the thesis does not breach copyright or other intellectual property rights of
a third party. yes
 I declare that the thesis does not contain material which has been accepted, or
submitted, for any other degree or diploma at a university or other institution of higher
learning. yes
 I declare that the thesis does not contain substantial portions of third party copyright
material, including – but not limited to – charts, diagrams, graphs, photographs or maps.
In instances where it does, I have obtained permission to use such material and allow it
to be made openly accessible in an appropriate repository. yes
For more information about Copyright see

Student signature Date

Conditions of use
Following examination the final version of the thesis will be deposited in the UC Research Repository
in the UC Library. I agree and acknowledge that the conditions of use are as follows:

1. This thesis may be consulted for the purposes of private study or research provided that
appropriate acknowledgement is made of its use;

2. The digital copy is made available via the Internet by the University of Canterbury Library in
downloadable format provided that the thesis is not subject to an embargo. Should an embargo be
in place, the digital copy will only be made available as set out above once the embargo has expired.

Student signature: Date:

Thesis embargo

This section should be completed after consulting the “Policy on Availability of Theses and Dissertations”.

(tick as appropriate)

I do not wish to apply for an embargo

I wish to request an embargo of this thesis for months (to a maximum of 24) from the date of
receipt of the thesis by the Library on the basis that (please tick as appropriate):

it contains commercially sensitive material which will breach prior contractual

arrangements with an outside organization

access will endanger protection of future intellectual property rights

(including opportunity to publish or make application for a patent)

the research uses personal sources and/or contains sensitive cultural

information which has been obtained on condition that the items be restricted
Other (please specify)

I wish to request an embargo as my thesis is classified as a Sensitive thesis - this is

necessary to ensure compliance with the law or protection of national interests or public
safety, may include objectionable or offensive material. This thesis will be permanently

Student signature Date:

Senior Supervisor Date:

Sensitive Thesis (only)

DVC (R&I) signature Date:

The final copy of the thesis has passed examination and is approved for deposit in the
University Library. The embargo period specified above is approved:

Dean of Postgraduate Date:


University Librarian Date: