Educational CyberPlayGround ®

Sample Copyright Request For Permission To Use Media Form Letter

Walker, Alice. "Copyright Law as Applied to Multimedia Productions" SUCCEED WWW Server (1995) Available

Sample Letter Requesting Permission

Permissions Department Date: ___________

Company Name -- Address -- City -- State -- ZIP

Dear Reader:

This letter is a request for permisson to duplicate / use for the following:

Title: Copyright: Author(s):

Material to be duplicated: copy enclosed

Manner of distribution:

Type of reproduction:

Purpose of use/reproduction:
inclusion in ( specify ) A self-addressed, stamped envelope is enclosed for your convenience.

Please respond.


School Name:
Address: City, ST ZIP
FAX: Phone:
Permission granted by Date / Conditions, if any: _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________

Created by Carol Mann Simpson and included in her book Copyright for Schools: a Practical Guide, 2d ed. Linworth Pubishers. ISBN 0-938865-57-9. Adapt it or use it with credit given to Carol Simpson.

Sample Letter Requesting Permission

Appendix A: Sample Authorization Request Form
Request for Authorization to Duplicate and / or Display Copyrighted Material




We are requesting authorization to use the following copyrighted materials:

Title: _____________________________

From: _____________________________

Medium: _____________________________






Producer Reply:

Permission: ___ Granted ___ Denied

Details / Restrictions:






Signature: ____________________ Title:___________________
Date: _________________

Sample Letter Requesting Permission

Appendix B: Sample Release Form
(Please fill out a complete typewritten release form for each visual submitted.)

1. Format:
__ Slide __ Overhead __ Video/film segment __ Computer animation __ Other (Please specify)

2. Year created: __________

3. Description (25 words or less):

4. Keyword descriptors (at least two): ______________________________

5. Suggest course or area of study for which this image may be appropriate:

6. Contributor:


Address: __________________________

City, state, zip: ________________________________

Telephone: _____________________


7. I hereby agree to lend the above described material for use in the [name the program here ], with the understanding that due care will be taken, and the material will be returned in timely fashion. I acknowledge that the materials may be duplicated and distributed in any and all manner and media throughout the world in perpetuity. I further warrant and represent that I possess all rights to these materials and will indemnify and hold [name all the programs involved], their licensees and assigns, harmless from and against any and all claims, damages, liabilities, costs and expenses arising out of a breach of the foregoing warranty.

_______________ date


Mail to:
Your Name
Business Name
Town, State, Zip

Sample Letter Requesting Permission
The request should be sent, together with a self-addressed return envelope, to the permissions department of the publisher in question.

Permissions Department



Dear Permissions Editor:

I am writing to ask your permission to (circle all that apply)

  • reprint
  • photocopy
  • quote from
  • incorporate into

    • multimedia courseware
    • online course materials
    • a dissertation/thesis
    • a print publication

the following material:

  • Author:
  • Book Title:
  • Journal Title:
  • Vol. Issue
  • Page #(s) Figure
  • Image #(s) Table #(s)

The material will be distributed/published as follows:



Expected distribution/publication date:

Expected length of work (number of images, etc.):

Target market:

If you do not solely control copyright in the requested materials, I would appreciate any information you can provide about others to whom I should write, including most recent addresses if available.

[Optional: Enclosed please find a draft License Agreement for your convenience in responding to this request.]


Please initial any statement that applies:

____I hereby represent that I have the authority to grant the permission requested herein.

____ I am the sole owner/author of the work.

Author Signature Company Signature

___________________ _______________________

Author's name Name of authorized signatory

___________________ ___________________




___________________ Company


___________________ ___________________

Date Date