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 and educational?
what role or function does the copyrighted work fulfill?
supplemental learning materials?
core learning materials?
entertainment or reward?
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.]