Copyright Request Letter
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.
____________________________
Signature
____________________________
Printed name
_____________________________
Date