Permission Request Form

Subject Line for Permission Request

First Name

Last Name

Title/Position

Institution/Organizational Name

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Phone

Extension

Your Email

Title of the Publication/Work Being Requested

Author

Specific Pages/Sections/Figures/Tables/URLs to Be Copied

Publication Date

Will this be reprinted

In a publication

As freestanding material

Name of publication or article that will include the requested material

Author of new publication

Publisher or journal

Expected Publication Date

Other Comments

Estimated size and occupation of audience

Number of freestanding copies that will be printed

Is this for one-time use?

Yes

If no, please explain

Formats

Print only

Electronic only

Print and Electronic

Other...

Briefly describe how the reprinted material will be used

The primary purpose of this use is

Educational

Commercial

Other...

Please briefly explain

Is the requestor an author of the material being requested?

Yes

*Please note that this is only a request and not a grant of permission. If approved, a Permissions Agreement will be sent to you for signature and is not in effect until signed by both parties and all fees are paid (if applicable).