Sample Permission Letter

To: Mr. John Doe
Copyright and Permissions Officer
Random House Publishers
332 Fifth Avenue
New York, New York 20021

From: Ms. Jane Dobson
Library Director
Mabee Library
Washburn University
1700 SW College
Topeka, Kansas 66621

Date: December 4, 2001

RE: Permission to duplicate a book chapter

Dear Mr. Doe:

This letter will confirm our recent telephone conversation. I request permission to reprint the following chapter in a coursepack for ED 565, Introduction to Educational Research, for use during the Spring 2002 semester.

Author(s): Robert Jackson
Title (edition, volume): Studies in Modern Education, 3rd ed.
Copyright date: 1999
Material to be duplicated (chapter, pages): pages 45-67, Chapter 3 - "Multiple Intelligences in the Classroom"
Number of copies: 23
Form of distribution: supplied to students free of charge for classroom use
Type of reprint: photocopy

A photocopy of the material is enclosed. Unless you indicate otherwise, the material will be accompanied by the following credit line and copyright notice:

Copyright ©1999 by Robert Jackson. Reprinted with permission from publisher. All rights reserved by the original copyright holder.

Thank you for your prompt consideration of this request. Enclosed is a stamped, self-addressed envelope to send back the signed permission form.

Sincerely,

[your signature]

RELEASE FORM

 Permission is granted for the use requested above.

 Permission is not granted for the use requested above, for the following reason(s):

_________________________ _________________________
Signature Date

(Name, Title)
(Institution)
(Fax # / Phone # / Email)