Reprint Permission Form

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Reprint Permission Form
Original Publisher
Material Requested:
Author:
Date Published:
Title:
Chapter:
Excerpt:
Page Numbers:
Publisher:
Address:
Request
Requestor’s Name:
Date:
Requested on Behalf of:
Manner of Use:
Requestor’s Publication:
Date to Be Published:
Requestor’s Phone No.
Requestor’s Email:
Requestor’s Address:
I,
, the requestor, understand that
permission may be denied without explanation. I will print the material as an excerpt or
in its entirety according to the authorization granted by the publisher or author. The
reprinted material will include the original author’s name and the date first published.
It will also include the statement “Reprinted with Permission from
Requestor’s Signature
Date Signed
Grantor
I, the
, am authorized to approve the following transaction.
I grant the request the right of one-time use of the aforementioned material on the
stated conditions and with the following stipulations:
Name:
Title:
Signature:
Date:

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