Copyright Permission Request

[date]

[address]

Dear [salutation]

I am writing to request permission to reproduce the following:

[title, author, series, producer, year produced]

This material is required for [insert use, for example teaching and give unit code – including ongoing or one time].  A proper copyright acknowledgment will be given.  Please advise if you have a preferred form of acknowledgment.

Please indicate your response below and do not hesitate to contact me if you require further information.

Yours sincerely

[NAME]

ÿ              Permission granted with no fee, in perpetuity

ÿ              Permission granted for no fee, for this one time only

ÿ              Permission granted for a fee of $______

ÿ              Permission denied

_______________________           _______________________           _____________________

Name (please print)                           Signature                                           Date