Permission Request Form
Date of Submission: ______________________________
Information Pertaining to Our Book:
Title: ___________________________________________
Author: __________________________________________
Publisher/Imprint: _______________________________
Copyright Year: __________________________________
ISBN: ____________________________________________
Material you want to use: ________________________
(Please specify page number and/or approximate number of words)
A photocopy of the material in context must be provided.
Information Regarding Your Project:
Title: ___________________________________________
Author: __________________________________________
Publisher: _______________________________________
Territory needed: ________________________________
Print run/circulation: ___________________________
Price: ___________________________________________
Publication Date: ________________________________
Number of pages of your book: ____________________
Format (Hardcover/Softcover/E-book): _____________
Requester Information:
Name: ____________________________________________
Position: ________________________________________
Company: _________________________________________
Address: _________________________________________
City: ____________________________________________
State: ___________________________________________
Zip Code: ________________________________________
Phone: ___________________________________________
Fax: _____________________________________________
E-Mail: __________________________________________
Please allow 3-5 weeks for a response. A self-addressed stamped envelope would be appreciated.