SAMPLE PERMISSIONS LETTER
Items between angle brackets are for you to fill in or delete, as applicable. Items in square brackets are notes to you.

<Author's return address>

<Name and address of publisher>

I am <writing, editing> a book entitled
to be published by <name of press>
<city and state of press>
in <year>.

The book will be published by <a nonprofit university press> in a <scholarly nontrade
edition> of < > copies. [If paper and cloth, give number of copies each.]

May I have your permission to include the following material in my book and in future revisions and editions thereof<, including nonexclusive world rights in all languages>? These rights in no way restrict republication of your material in any other form by you or others authorized by you. Should you not control these rights,
I would appreciate your telling me where to write.

Book <or journal> title [book or journal title where material was originally published]:

<Article title> [if material was in a journal, otherwise omit this line]

Author: [or multiple authors, or editor(s)]

Copyright date:

<Figure:> [give number and full caption, especially if you’re using the caption; if you are adapting it, say so, and enclose photocopy of your adaptation; if multiple figures, or table(s), give each, with page number]

<Photo:> [give number and caption; if multiple photos, or illustration(s), give each, with page number ]

Page:

<Opening words:> [use this and next item for prose and poetry material; also attach photocopy of material]

<Closing words:>

I plan to use the following credit line, unless you prefer another (see form below):
[give author or editor, title, city, publisher, date, page or pages, number of figure or table, other identifying characteristics if applicable]

I appreciate your consenting to this request as soon as possible. A release form is provided below, and a copy of this request is enclosed for your files.
Sincerely, ________________
Signature
________________
Date


I grant permission for the use of the material requested above.

______________________________________________________ _________________
Name and position Date

Address
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Credit line requested, if different from above
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________