Form to Request Reprint Permission

Form to Request Reprint Permission
If you plan to use any material that some other entity owns the rights to you must obtain a written release before offering such materials for reprinting in your project. This is often the case with photos and art supplied by others. It can also pertain to excerpts of text.

Always consult an attorney for legal advice. I am not a lawyer and am not offering you legal advice. The following form is for illustrative purposes only and is NOT to be used for legal purposes.

The sample form below is representative of the type of form that you would likely use to obtain permission to reprint something that some other entity has control over the rights for.


Request for permission to reprint material
To: (please print or type) From: (please print or type)

Person (if known)
Title (if known)
Company
Address
Address
Telephone
E-mail
Fax
Dear Copyright Holder:
Author
Address
Address
Telephone
Date
E-mail
Fax

I am preparing a book to be published by ___________________________ that is tentatively titled
__________________________________________________and that has an estimated publication date of _______________________________. It will number approximately _____________ pages.
I request your permission to use the following material in this and all subsequent editions of my book, including all foreign-language translations and electronic formats (for example, CDROM and the Internet), published by the publisher or its licensees for distribution throughout the world. I also request permission for possible use of the material in conjunction with the promotion of my book.
Please indicate your agreement by signing and returning this letter. In signing, you warrant that you/your organization are/is the sole copyright owner(s) of this material and that said copyright does not infringe on the copyright or other rights of anyone else. If you do not control these rights, I would appreciate your letting me know to whom I should apply.
Thank you.
Sincerely,
Signature
Text material
Authors/editors _____________________________________________________________

Title of book/periodical/selection _______________________________________________ From page _________, line _________, beginning with the words __________________________________
To page _________, line _________, beginning with the words ____________________________________
Artwork
Figure nos. _________________________________________________ on page(s) ____________________________
Table nos. __________________________________________________ on page(s) ____________________________
Other
Agreed to and accepted by:
Name (please print or type) Signature Date
Title (please print or type)
Check one if permission is granted:
• No specific credit line or acknowledgment is necessary or desired.
• Mention of my name / company name (circle one or both) on the acknowledgments or copyright page of the book is sufficient.
• Include a credit line of the following simplified form, which is the publisher’s standard format: XYZ Widget Company.
• Include a credit line to be worded as follows (please print or type):

Author and Publisher use only
Please identify which text passages/figures/tables in your submitted manuscript correspond to those referenced above.
Original source (e.g. page/figure #) Appears in manuscript as (e.g. figure #/table #)