Rights & Permissions Form

PLEASE FILL OUT THIS FORM

Please, if possible, attach a copy of the story or drawing that you are requesting. Payments made on Permissions are not refundable. Thank you.

Full Name of person making request (Required)Your TitleStreet Address

City, Town, or Village

State / Province

Postal Code

Phone Number (Required)

Fax Number

Email Address (Required)Requesting a Permission for (Please all that apply):

Written Material

Drawing

Cartoon

Photography

AUTHOR or ILLUSTRATOR of material you are requesting from us:TITLE of Book(s) or CAPTIONS on Cartoons:TITLE of Short Story(ies)/Play(s) within the above edition:Original Copyright Date(s):Are you using the complete story/play?YesNoOr Excerpt/Quote: (indicate which)Number of Pages:Number of Words:

If requesting an excerpt, please give us the exact material you are using by typing the opening and closing words and detailing where in the story the excerpt appears. Please attach a copy of the excerpt, if possible

Location within Story:OPENING WORDS:CLOSING WORDS:

YOUR BROADCAST INFORMATION:

Radio Station:Name of Program:Date of Broadcast:

YOUR BOOK INFORMATION:

ISBN number:Complete title of your work, book, material in which quotation or excerpt will appear:Author/Editor (specify which) of your work and anticipated number of pages in your volume:Please indicate how you wish to use this material; in context of a chapter, epigraph, etc.Your work will be:HardcoverSoftcoverE-BookCD-RDVDEstimated number of copies and price (ALL printings, not just first print run):Market in which your work will be distributed:United StatesUnited States & CanadaUKWorldOther Market (please describe):Hardcover, Softcover or Other (specify):Is our material to appear on a password-protected Web site?Please provide the Web address:

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