[Rights holder name and address]

Dear Permissions Editor [Insert name, if known]:

I am in the process of creating [Describe project]. I would like your permission to include the following material in this project:

[Citation of material for which permission is sought, specifying exactly what material would be used]

The [Name of Project] will be used [Describe how the project and material will be used]. It will be available to [Specify who the users will be and how they will gain access, including any charges or fees involved].

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 non-exclusive 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 greatly appreciate your consent to my request. If you require any additional information, please do not hesitate to contact me. I can be reached at:

[Your contact information]

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.



[Printed Name]

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

Agreed to: __________________________ Name & Title: _______________________
Company/Affiliation: __________________ Date: ______________________________ 

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