Date

Your name
Address 1
Address 2
City/State/Zip
e-mail and/or website

Name of copyright holder
Address 1
Address 2
City/State/Zip

Dear Sir or Madam (Permissions Editor):

I am in the process of creating a book titled ____________________, to be published by ________________________________________. I would like your permission to include the following material:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

The material will be used (briefly describe how it will be used). 
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

A credit will be included in the following format:

Courtesy of (your company name). All rights reserved.
 
If you prefer other wording, please provide it below:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

If you do not control the copyright on all of the above mentioned material, I would appreciate any contact information you can give me regarding the proper rights holder(s), including current address(es). Otherwise, your permission confirms that you hold the right to grant the permission requested here.

Permission includes nonexclusive world rights in all languages to use the material and will not limit any future publications, including future editions and revisions, by you or others authorized by you.

I would appreciate your consent to my request. If you require any additional information, please do not hesitate to contact me.

A duplicate copy of this request has been provided for your records. If you agree with the terms as described above, please sign the release form below and send one copy with the self-addressed return envelope I have provided.

Sincerely,
________________________________________ 


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Permission granted for the use of the material as described above:

Agreed to by (signature): _________________________________

Name and title: _____________________________________________

Company/affiliation: _______________________________________

Date: ______________________________