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Your Name             Address                                                                                           Date       Permissions Dept. or Author' name Address                                                                                                                   Subject: Requested permission to quote from a periodical Dear       , I am writing to request permission to use the following material for use in a (book or article) I am writing entitled       . I have enclosed a self addressed stamped envelope and attached a “PERMISSION GRANTED” form for you to sign and send back for your convenience. The following is the information that I wish to use: Item Information To Be Used Name of author/editor/translator: Title: Edition: Volume Number: ISBN/ ISSN: Page Numbers to be used: Number of exact pages, figures and illustrations: Material begins on page       , line       , through page       , line       , beginning with the words “                         ” and ending with the words “                         ,” and consisting of a total of             words. Thank you for your prompt attention to this matter and for your consideration of this request. Sincerely, Your Name             C.C. - 1 – Copyright 2004 USLegalforms.com PERMSISION GRANTED FORM I,       , as author/editor/translator hereby grant permission for       to use the aforementioned works and granting non-exclusive world rights in all languages in the book/article titled       , and for any subsidiary use, promotional use, future revisions, and future editions of the same. A fee of $       shall be charged for this use. This is a limited use license, limited to the aforementioned specific use. This grant of permission shall expire on the following date:             . The following credit line and copyright notice must accompany the use of this material:       . By: ______________________       Date       Title - 2 – Copyright 2004 USLegalforms.com