REPRODUCIBLE PERMISSION REQUEST FORM to use for material that needs to include permission to allow purchasers to photocopy it (such as forms to fill in, handouts, etc)  PLEASE RETYPE ON YOUR OWN LETTERHEAD

[DATE]

[COMPANY/COPYRIGHT HOLDER]
Attn: Permissions Dept.
[ADDRESS]
[ADDRESS - 2]

Permission Request

I am preparing a manuscript to be published by Guilford Publications, Inc:

Book Title:
Author:
Estimated Publication Date:
Estimated Number of Total Pages:
Approximate Print Run:
Tentative Price:

May I have your permission to use the following material:

Book/Journal title:______________________________________________________________
Author(s) and/or editor(s):________________________________________________________
Title of Selection:_______________________________________________________________
From page__________ to page __________.         Copyright Year/Journal Date:______________
Figure# __________________ on page_________     Table#________________ on page___________

(If necessary attach continuation sheet or sample of requested material)

in this publication, and in future revisions and editions thereof including non-exclusive world rights in all languages, bookclub rights, electronic rights as that term is commonly understood in the publishing industry, including all rights under U.S. Copyright Law to exploit the Work and derivative works in all electronic and on-line media now known and hereafter to be developed, in all languages throughout the world, including versions made by non-profit organizations for use by blind or physically handicapped persons.  It is understood that full credit will be given to the author and publisher.

In addition, we would like to request permission to grant purchasers of our book the non-assignable right to copy (including the limited right to download to a single computer) the material described above only for personal use with their clients or students. Please confirm that you are willing to grant this permission.   

Please indicate your agreement by signing and returning this form. In signing you warrant that you are the sole owner of the rights granted and that your material does not infringe upon the copyright or other rights of anyone. If you do not control these rights, I would appreciate your letting me know to whom I should apply.

Sincerely,

‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑‑
I (we) grant permission for the use requested above, including the specific right for purchasers of the book  to photocopy the material for use with clients/students.

X                                                                                        Date:_______________________

Print Name: __________________________________