Permission to Reprint Request Form

If you are requesting permission to reprint copyrighted material that exceeds 150 words, please complete the form below.

Contact Information
Name
First Last
Company
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Email
Preferred contact method
- Email
- Fax
- Phone
- Letter
Material Being Requested
Name of Book
Original Author of Book
Editor of Book (if known)
If part of a collection, Title of specific chapter or article requested
If part of a collection, Author of Specific article or section requested
Selection Identification (page numbers of where the material is printed)
Use
Type
- Commercial
- Academic
- Translation
Please provide a brief statement your proposed use of this material
Academic Use
Title of course
Instructor name
Course Start Date
MM slash DD slash YYYY
Course End Date
MM slash DD slash YYYY
Approximate percentage of the entire course materials this selection will compose
Commercial Reprint and Translation Use
Is your company nonprofit?
- Yes
- No
Brief Company Overview
Title of publication
Author/Editor
Publisher
Proposed Publish Date
MM slash DD slash YYYY
Hardcover Price
Paperback Price
Web Price
Distribution
Language
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Contact Information