Date
Publisher Name
Publisher Address

Re: Request for Permission to Reproduce Copyrighted Work

Dear ____________:

I am a faculty member in the Department of { } at Valparaiso University, a non-profit institution of higher education. Please consider this letter a request for permission to reproduce the following work for use by my students in my course entitled {….}:

Title and edition of book:
Copyright and Year:
Author:
Material to be duplicated:
Number of copies:
Type of reproduction:
Distribution and use:
Duration of use:

Please indicate whether you are granting permission by circling the appropriate response, signing, dating and returning the enclosed copy of this request. I am also enclosing a pre-addressed stamped envelope for your convenience in replying to this request.

Sincerely,

 

Signature
Printed name

 

Permission is hereby granted/not granted to reproduce the foregoing copyright materials for the stated purpose.

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Signature

____________________________
Printed name

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Date