Sample Copyright Request For Permission To Use Media Form Letter
A SAMPLE COPYRIGHT REQUEST FOR PERMISSION TO USE FORM LETTER
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.
Sincerely,
Name:
School Name:
Address: City, ST ZIP
FAX: Phone:
Permission granted by Date / Conditions, if any: _____________________________
_____________________________
_____________________________ _____________________________ _____________________________
_____________________________ _____________________________
Sample Letter Requesting Permission
Appendix A: Sample Authorization Request Form
Request for Authorization to Duplicate and / or Display Copyrighted
Material
Date:
To:
From:
We are requesting authorization to use the following copyrighted materials:
Title: _____________________________
From: _____________________________
Medium: _____________________________
Use:
_____________________________
_____________________________
_____________________________
_____________________________
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:
Name:_____________________________
Address: __________________________
City, state, zip: ________________________________
Telephone: _____________________
e-Mail:____________________
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
_________________________________
Signature
Mail to:
Your Name
Business Name
Street
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
[Publisher]
[Address]
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:
Distribution:
Publisher:
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.]
Sincerely,
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
___________________ ___________________
Title
___________________
___________________
___________________ Company
Address
___________________ ___________________
Date Date