Permissions Form

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.