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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

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:

Book Title:
Journal Title:

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.


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



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