
Sample written request for permission
Permissions Department
[Publisher]
[Address]
Dear Permissions Editor:
I am writing to ask your permission to (include all that apply)
- reprint
- photocopy
- copy in digital form
- quote from
- incorporate into
- multimedia courseware
- online course materials
- a dissertation/thesis
- a print publication
- an electronic publication
the following material:
Author: Book Title: Journal Title: Vol. Issue Page #(s) Figure/
Image #(s)Table #(s)
or material located at: [url].
The material will be distributed/published as follows:
Distribution (describe, including medium):
Publisher (if applicable):
Expected distribution/publication date:
Expected length of work (number of words, pages, images, etc., as appropriate):
Target market:
If you do not solely control copyright in the requested materials, I would appreciate any information you can provide about others to whom I should write, including most recent contact information, if available.
Sincerely, | Copyright proprietor, please initial any statement that applies:
|
Author Signature | Company Signature |
___________________ Author's name |
_______________________ Name of authorized signatory |
___________________ ___________________ ___________________ Address |
_______________________ Title _______________________ Company |
___________________ Date |
_______________________ Date |

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