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