Republication Permission Request Form

Please fill in all the fields. Incomplete requests will not be processed.

EMAIL ADDRESS:
YOUR NAME/ MAILING ADDRESS/ FAX NUMBER:
YOUR REFERENCE NUMBER (IF APPLICABLE):
TITLE OF THE BOOK OR JOURNAL YOU ARE REQUESTING FROM:
NAME OF THE PRIMARY AUTHOR OR EDITOR OF THE BOOK - do not include the name(s) of the chapter author(s) (journal requestors skip this field):
JOURNAL VOLUME & ISSUE NUMBER/MONTH/YEAR (Book requestors skip this field):
ISBN (Journal Requesters skip this field):
SPECIFIC PAGES AND FIGURE NUMBERS YOU WISH TO USE:
TITLE OF YOUR WORK:
YOUR PUBLISHER:
EXPEECTED PUBLICATION DATE:
FORMAT:




IF WWW PLEASE GIVE THE URL WHERE THE MATERIAL WOULD BE SITED:
IF WWW OR INTRANET, IS THE MATERIAL REQUESTED FROM A BOOK USED FOR A RECOGNIZED COURSE?:
IF WWW OR INTRANET IS THE WEB SITE WHERE THE MATERIAL WILL BE POSTED PASSWORD PROTECTED, OR IS ACCESS TO THE SITE LIMITED IN ANY WAY?

IF CD-ROM OR SOFTWARE PROGRAM, GIVE THE SIZE OF THE PRINT RUN:
PLEASE INDICATE ANY PARTICULAR CIRCUMSTANCES REGARDING THIS REQUEST, FOR YOU ARE THE AUTHOR OF THE REQUESTED MATERIAL: