Fill and Sign the Request for Permission and Agreement Granting Permission Form

Request for Permission and Agreement Granting Permission to Reprint Copyrighted Material To:________________________ (Name of copyright owner) ______________________________________________ (Address of copyright owner) The undersigned, _____________________ (name of proposed user) , of __________ ___________________________________________________________________ (street address, city, state, zip code) , hereby requests permission to reprint for circulation in the United States and its dependencies and not elsewhere from your publication entitled ________________________ (title of publication) the following material: (Description of material including details such as page numbers, paragraphs, and approximate number of words) ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________. This material is to appear without change in a Book entitled _______________________ (Title of Book) , by ____________________ (name of author) , to be published by the undersigned Publisher. The probable date of publication is __________________ (date.) The probable price of said Book is $___________ and the probable size of the Book is _______ pages. The undersigned agrees to give full credit to __________________ (name of author) in the following form on the copyright page or the first page on which the selection appears: (words of credit) _____________________________________________________________. The undersigned promises and agrees to restrict the use of the selections herein described to the Book described above and to pay you on or before the date of publication the fee of $___________. The undersigned further promises and agrees to forward to you one copy of the Book on or before publication. If the Book is allowed to go out of print, all rights granted in this agreement automatically revert to you, and all permissions are terminated, except that the rights extend to revised editions where changes in content do not exceed ________ (fraction) of the original text. Witness my signature this __________________ (date) . ____________________________ Printed Name of Requesting Party ____________________________ Signature of Requesting Party The undersigned ________________________ (Name of Copyright Owner) does hereby grant my permission on the terms set forth above. Witness my signature this ________________ (date) . ____________________________ Printed Name of Owner ____________________________ Signature of Owner