Copyright Permission: Permission Letter Template

Date

Department of Permissions and Licensing

Hypothetical Publishing Company

### Some St.

Some City, Some State  12866

To Whom It May Concern:

I would like permission to use the following materials:

Full citation information:

Material to be used: [Chapters, page numbers, paragraphs, time stamps go here]

As concisely as possible, write a paragraph or two describing the following information:

• are you using it as-is or making a derivative work (translation, adding accessibility features, adaptation, format conversion, sequel, spinoff, supplemental material…)?

• will it be accessed online or face to face?

• will it be to the public or a limited audience?

  • if it’s just a certain number of copies, how many copies?

  • if limited, how many people?

  • if limited, how is the limitation enforced (password? registered attendees of a conference? enrolled students in a class?

• how are you providing access to it?

  • learning management system?

  • electronic reserves system?

  • public web site or blog? (provide the name and URL if you can)

  • reprinting it in a book or article? (provide information about it)

  • including it in a conference presentation?

  • display/performance/copies in a face-to-face setting?

• is your use commercial in any way?

  • non-profit?

  • non-profit and educational?

• what role or function does the copyrighted work fulfill?

  • supplemental learning materials?

  • core learning materials?

  • entertainment or reward?

  • illustrating something?

  • serving as an example of something?

  • component of a mash-up or remix?

  • basis for an adaptation or translation?

[If not using email: I have enclosed a self-addressed stamped envelope for your convenience in replying to this request.]

Sincerely,

Your name