Copyright Permission Form Example

From: ____________________________

Position: _____________________

Date: _________________

To:

We request permission to duplicate materials for the use below. Use will be exclusively for educational purposes and will have no commercial advantage.

Title:

Author:

Publisher:

Copyright Date:

Number of Copies:

Use of Item:

Other Pertinent Notes:

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Please indicate your permission below, and return this form as soon as possible.

A return envelope is enclosed for your convenience.

Permission Granted

Permission Granted with the following restrictions

______________________________________________
______________________________________________
______________________________________________

Permission Denied

Name: ______________________________

Position: ____________________________

Date: _______________________________