REQUEST FOR PERMISSION TO REUSE PREVIOUSLY PUBLISHED MATERIAL

TO: Rights & Permissions Department

Publisher:

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E-mail:

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Requestor’s Contact Information

First name:

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We seek permission to reuse material previously published in one of your publications and intend to
include the material(s) in a new manuscript being submitted to another publisher. For such purpose,
we request nonexclusive world rights in all media and editions for the following material(s):

Full title of journal or book:

ISSN or ISBN:

Names of author(s):

Full title of article or chapter:

Volume: Issue: Year: Page range: Article ID:

Figure number(s) Table number(s)
(if applicable): (if applicable):

Description of material to be reused:

Should permission for reuse is granted, the publication in which the material will be reused is shown
below:

Title of proceedings:

Publisher:

Media (select all applicable)

Expected publication date: Print CD Online

Names of authors:

Full title of article (or chapter):

Please reply with your answer and other special instructions (if any), to the e-mail address shown
above.

Sincerely (requestor’s name)

REPLY FROM ORIGINAL PUBLISHER: The above request is hereby approved on the conditions specified
below, and on the understanding that full credit (including author, publication, publisher, copyright
year, etc.) will be given to the source.

Approved by (print name):

Approved by (signature):

Date of approval:

Conditions and required credit line: