Permission Request Letter

[Date]
[Company Name]
[Company Address]

Attn: Permissions Department

Re: Permission Request
My Reference No. [insert your manuscript pate no.]

Dear Sir or Madam:

I would like to obtain permission to use the following material for a book I am preparing for
[name of publisher], the details of which are as follows:

[Proposed Usage]

Tentative Title of Work:

Author(s):

Publisher:

Publication Date:

Tentative Price:

Initial Print Run:

Format/Medium: [e.g., 176 pages, trade paperback]:

[Rights Sought]

[Option 1: Broad Grant of Rights] “The nonexclusive right to include the following material, in
whole or in part, in this and all subsequent editions of my book (in print, electronic or other
formats), in all foreign language translations and other derivative works published or prepared by
me, or my successors, assigns or licensees, for distribution throughout the world.”

[Option 2: Narrower Grant of Rights] “The nonexclusive right to include the following material,
in whole or in part, in this and all subsequent editions of my book (in print, electronic or other
formats), in English and other derivative works published or prepared by me, or my successors,
assigns, or licensees, for distribution throughout [the world] [the United States, its possession,
territories, and Canada].” [Strike one out.]

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I understand that you are the sole and exclusive owner of the aforementioned rights and that you
have the right and power to grant me permission to include the following material into my book
and that there are no other agreements with any other party in conflict herewith.

[Material Requested]

Title of Book/Periodical/Journal:

Full Name of Author(s):

Volume/Issue/Edition #:

Date of Publication [copyright date or issue date]:

ISBN [books only]:

ISSN [journals/periodicals only]:

Beginning on page ___, line ___, with the words .

Ending on page ___, line ___, with the words .

Illustration/Figure No. ___ on page ___ (photocopy attached for ease of reference).

Chart no. ___ on page ___ (photocopy attached for ease of reference).

In consideration for the grant of the nonexclusive right to include the aforementioned material, I
agree to pay you the sum of (enter amount) due and payable upon execution of this letter by both
parties.

Kindly grant our request for the aforementioned rights by signing and returning to me a signed
copy of this letter. If you do not control the rights, or if additional Intellectual Property
permissions are needed, kindly indicate below whom I should contact.

This letter shall be construed and enforced in accordance with the laws of the United States of
America and of the State of (enter state) and constitutes the entire and only agreement between
the parties and all other prior negotiations, agreements, representation and understanding are
supersede hereby.

A self-address stamped envelope is enclosed for your convenience.

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Thank you.

Sincerely yours,

[Your signature]

[Your name]

[Address]

[Phone/Fax/E-mail]

By:
Authorized Signature

Name:

Title:

Credit Line:

Copyright Notice:

Other Remarks:

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