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US flag 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:

  • I hereby represent that I have the authority to grant the permission requested herein.
  • I am the sole owner/author of the work.
Author Signature Company Signature
___________________
Author's name
_______________________
Name of authorized signatory
___________________
___________________
___________________
Address
_______________________
Title
_______________________
Company
___________________
Date
_______________________
Date
Creative Commons Licence
Copyright Crash Course by University of Texas Libraries is licensed under a Creative Commons Attribution
3.0 United States License
. Based on a work at http://copyright.lib.utexas.edu/.