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HIGHER EDUCATION

Higher Education Committee:
Campus Copyright Education Program

Standard Permission Request Form
To
*Publisher Contact
*Publisher
Fax Number
Date of Request

From
*Your Last Name
*Your First Name
Department
School Name
Mailing Address
 
City
State
Province
Postal Code
Work Phone
Fax
E-mail
Number of Copies Needed
Instructor
Semester and Year
Book Title
Author
Translator
Editor
Edition
Volume
Publication Year
Chapter / Article Title
Page Numbers
Total Pages
Is it an out-of-print work?
Have you included a copy of
the material with this request?
Are you the author?
ISBN (Found on copyright page)
 
Fax or mail this sheet to the appropriate rights holder/publisher or copyright clearance service three to nine weeks before class begins. Permission is requested for use during one term only.
 
Permission is null and void if timely payment is not received.
 
Click to clear the form and start over.

 

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