permissions-form

Permissions Request Form

Requester contact information:

Name:

Title	First Required	Middle Required	Last Required	Suffix

Email: Required

Street 1: Required

Street 2:

City/State/ZIP:

City Required	State Required	ZIP Required

Country: Required

What's this?

*2.

Question - Required - What type of permission request is this?

Question - Not Required - Title of our book or article:

Question - Not Required - Chapter of book or source of article:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Date of our publication:

Month

Day

Year

Question - Not Required - Author:

Question - Not Required - Number of words requested to quote:

Question - Not Required - Description of the exact words you wish to use, including page numbers, chapter heads, opening and closing lines, along with a few lines of your work, which will immediately precede and follow the quoted material:

If requesting reprint:

Question - Not Required - Title of your work:

10.

Question - Not Required - Name of your publisher:

11.

Question - Not Required - Date of publication of your work:

Month

Day

Year

12.

Question - Not Required - Retail price (in U.S. dollars) at which your work will be sold:

13.

Question - Not Required - Countries in which your work will be marketed:

(Maximum response 255 chars, approx. 5 rows of text)

14.

Question - Not Required - Number of copies that will be printed:

If requesting photocopies:

15.

Question - Not Required - Number of copies to be made:

16.

Question - Not Required - For what purpose:

(Maximum response 255 chars, approx. 5 rows of text)

17.

Question - Not Required - When needed:

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