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Sample Letter Requesting Permission
The request should be sent, together with a self-addressed return envelope, to the permissions department of the publisher in question.
Permissions Department
[Publisher]
[Address]
Dear Permissions Editor,
I am writing to ask your permission to (circle all that apply)
- reprint
- photocopy
- quote from
- incorporate into:
- multimedia courseware
- online course materials
- a dissertation/thesis
- a print publication
the following material:
| Author: |
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| Book Title: |
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| Journal Title: |
Volume: |
Issue: |
| Page #(s) |
Figure/Image #(s) |
Table #(s) |
The material will be distributed as follows:
Distribution:
Publisher:
Expected distribution/publication date:
Expected length of work (number of images, etc.)
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 addresses if possible.
[Optional:]Enclosed please find a draft License Agreement for your convenience in responding to this request.]
| Sincerely, |
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.
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| Author Signature |
Company Signature |
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| _________________________ |
_________________________ |
| Author's Name |
Authorized Signatory |
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| _________________________ |
_________________________ |
| _________________________ |
Title |
| _________________________ |
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| _________________________ |
_________________________ |
| Address |
Company |
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