Sample Copyright Permission Request - For Use by Individual Faculty/Staff (Print out on K-State letterhead)
Date
Contact Name
Company Address
Phone./Fax/Email
Dear ____________:
I request permission to use the following material:
Nature of material (examples: book chapter, journal article, etc.) [Describe] ____________________________
Author(s): ___________________________________
Title of Article or Book: ________________________
Publisher s Name and Address: ______________________
Date of publication: ______
9
Volume/Issue (if applicable):
____________
Page numbers:
________
A photocopy of the material is enclosed.
I WISH TO USE THIS MATERIAL IN THE FOLLOWING MANNER:
Name of class:
Current class size: (please note if there are multiple sections)
Describe how the material will be used:
9 Class handout
9 Coursepack
9 Internet
9 Intranet
9 Linking
9 Email
9 Journal
9 Magazine
9 Newsletter
9 Newspaper
9 Presentation
9 Presentation Handout
9 Textbook
9 Tradebook
9 Dissertation
9 Pamphlet
9 CD ROM
9 Advertisement
9 Telnet 2 (statewide satellite delivery system)
9 Other (describe):
If used for a class, will material be kept by student or returned to the instructor
9 Yes
9 No
Dates/Duration of use: _________________
Unless you specify otherwise, the material will be accompanied on publication by the following credit line and copyright notice:
___________________________________ [specify credit line and copyright notice]
If you do not control the world rights to the requested material, please specify here any additional source from whom permission must be
obtained: __________________________________________________.
Thank you for your prompt consideration of this request. For your convenience, a release form is provided below.
Sincerely,
[your signature]
RELEASE FORM
9
Permission is granted for the use requested above.
9
Permission is not granted for the use requested above, for the following reason(s):
_________________________________
Signature
(Name, Title)
(Institution)
(Fax # / Phone # / Email)
______________
Date