Generic Permission to Reprint Form

 Request for permission to reprint material

To: (please print or type) From: (please print or type)

Person (if known)

Title (if known)

Company

Address

Address

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Dear Copyright Holder:

Author

Address

Address

Telephone

Date

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I am preparing a book to be published by ___________________________ that is tentatively titled

__________________________________________________and that has an estimated publication date of _______________________________. It will number approximately _____________ pages.

I request your permission to use the following material in this and all subsequent editions of my book, including all foreign-language translations and electronic formats (for example, CDROM and the Internet), published by the publisher or its licensees for distribution throughout the world. I also request permission for possible use of the material in conjunction with the promotion of my book.

Please indicate your agreement by signing and returning this letter. In signing, you warrant that you/your organization are/is the sole copyright owner(s) of this material and that said copyright does not infringe on the copyright or other rights of anyone else. If you do not control these rights, I would appreciate your letting me know to whom I should apply.

Thank you.

Sincerely,

Signature

Text material

Authors/editors _________________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Title of book/periodical/selection _______________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

From page _________, line _________, beginning with the words __________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

To page _________, line _________, beginning with the words ___________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Artwork

Figure nos. _________________________________________________ on page(s) ____________________________ _ _ _ _ _ _ _ _

Table nos. __________________________________________________ on page(s) ____________________________ _ _ _ _ _ _ _ _

Other

Agreed to and accepted by:

Name (please print or type) Signature                                                                                                                                                                                         Date

Title (please print or type)

Check one if permission is granted:

•                      No specific credit line or acknowledgment is necessary or desired.

•                      Mention of my name / company name (circle one or both) on the acknowledgments or copyright page of the book is sufficient.

•                      Include a credit line of the following simplified form, which is the publisher’s standard format: XYZ Widget Company.

•                      Include a credit line to be worded as follows (please print or type):

Author and Publisher use only

Please identify which text passages/figures/tables in your submitted manuscript correspond to those referenced above.

Original source (e.g. page/figure no.) Appears in manuscript as (e.g. figure no./table no.)