Date: ________________
Permissions Department
____________________
____________________
____________________
Dear ________________:
I would like permission to reproduce the following material for use as supplementary course reading during this semester (and/or subsequent semesters):
Title:
Edition or volume and issue date:
Publisher and copyright date:
Author:
ISBN or ISSN:
Material to be reproduced (chapter or article and pages):
Distribution method:
Number of copies:
The pages requested will be used as supplementary reserve readings for course title:
____________________________________________________________________
A stamped, self-addressed envelope is enclosed for your convenience in responding to this request, or you may respond by fax to ( ___ - ___ ) or by e-mail to ____ @ ________ .
Sincerely,
______________
enc.
Last Modified: October 10, 2012