Permissions Department
(Publisher)
(Address)
Dear Editor:
I am requesting permission to use the following materials in an online course at the University of Central Florida:
Author:
Book Title:
Journal Title: (Volume, Issue)
Page Number(s)
Figures/Image Number(s)
Table(s)
These materials will be used for the _____________ course which will be taught ____________________.
The purpose(s) of using these materials is (are)
__________________________________________________
__________________________________________________.
This course will be taught via the Internet. However, the course information is password protected and only students registered in the course have access.
If you do not solely control copyright of these materials, I would appreciate any names and addresses of whom to write.
Sincerely,
(Your name)
Please initial any statement that applies:
* ____ I hereby represent that I have the authority to grant the permission requested herein.
* ____ I am the sole owner/author of the work.
Author Signature
_______________________________
Author's name
_______________________________
_______________________________
_______________________________
_______________________________
Address
_______________________________
Date
Company Signature
_______________________________
Name of Authorized Signatory
_______________________________
Title
_______________________________
Company
_______________________________
Date