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Sample Permission Request

This is a sample only and should not be construed as a substitute for legal advice, nor is this resource comprehensive on the subject of copyright.

The request should be sent, together with a self-addressed return envelope, to the copyright owner (author) or permissions department of the publisher in question.


Copyright Owner
Permissions Department
Address
   or   
Publisher
Address


Dear Copyright Owner or Dear Permissions Editor:

I am writing to ask your permission to (circle all that apply)

  • reprint
  • photocopy
  • quote from
  • incorporate into
  • multimedia courseware
  • online course materials

the following material:

Author:
Book Title:
Journal Title:
Vol.:
Issue:
Page(s):
Figure/Image(s):


If you do not solely control copyright in the requested materials, I would appreciate any information you can provide about others to whom I should write, including most recent addresses if available.

Sincerely,

Your signature


Please initial any statement that applies:

_________ I hereby represent that I have the authority to grant the permission requested herein.

_________ I am the sole owner/author of the work.

________________________________________________________________
   Name of authorized signatory

_______________________________________________________________
   Date

________________________________________________________________
   Title

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