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Sample Copyright Request For Permission To Use Media Form Letter

A SAMPLE COPYRIGHT REQUEST FOR PERMISSION TO USE FORM LETTER
Walker, Alice. "Copyright Law as Applied to Multimedia Productions" SUCCEED WWW Server (1995) Available http://succeed.engr.vt.edu/copyinfo.html

Sample Letter Requesting Permission

Permissions Department Date: ___________

Company Name --  Address   -- City -- State -- ZIP

Dear Reader:

This letter is a request for permisson to duplicate / use for the following:

Title: Copyright: Author(s):

Material to be duplicated: copy enclosed

Manner of distribution:

Type of reproduction:

Purpose of use/reproduction:
inclusion in ( specify ) A self-addressed, stamped envelope is enclosed for your convenience.

Please respond.

Sincerely,


Name:
School Name:
Address: City, ST ZIP
FAX: Phone:
Permission granted by Date / Conditions, if any:  _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________

Created by Carol Mann Simpson and included in her book Copyright for Schools: a Practical Guide, 2d ed. Linworth Pubishers. ISBN 0-938865-57-9. Adapt it or use it with credit given to Carol Simpson.

 

Sample Letter Requesting Permission

Appendix A:  Sample Authorization Request Form
Request for Authorization to Duplicate and / or Display Copyrighted Material

Date:

To:

From:

We are requesting authorization to use the following copyrighted materials:

Title: _____________________________

From: _____________________________

Medium: _____________________________

Use:

_____________________________

_____________________________

_____________________________

_____________________________

Producer Reply:

Permission: ___ Granted ___ Denied

Details / Restrictions:

_____________________________

_____________________________

_____________________________

_____________________________

_____________________________

Signature: ____________________ Title:___________________
Date:   _________________

 

Sample Letter Requesting Permission

Appendix B: Sample Release Form
(Please fill out a complete typewritten release form for each visual submitted.)

1. Format:
__ Slide  __ Overhead __ Video/film segment  __ Computer animation  __ Other (Please specify)

2. Year created: __________

3. Description (25 words or less):

 

 

4. Keyword descriptors (at least two): ______________________________


5. Suggest course or area of study for which this image may be appropriate:

 

 

 

6. Contributor:

Name:_____________________________

Address: __________________________

City, state, zip: ________________________________

Telephone: _____________________

e-Mail:____________________

7. I hereby agree to lend the above described material for use in the [name the program here ], with the understanding that due care will be taken, and the material will be returned in timely fashion. I acknowledge that the materials may be duplicated and distributed in any and all manner and media throughout the world in perpetuity. I further warrant and represent that I possess all rights to these materials and will indemnify and hold [name all the programs involved], their licensees and assigns, harmless from and against any and all claims, damages, liabilities, costs and expenses arising out of a breach of the foregoing warranty.

_______________ date

 

_________________________________
Signature

Mail to:
Your Name
Business Name
Street
Town, State, Zip

 

Sample Letter Requesting Permission
The request should be sent, together with a self-addressed return envelope, to the permissions department of the publisher in question.

Permissions Department

[Publisher]

[Address]

 

 

Dear Permissions Editor:

I am writing to ask your permission to (circle all that apply)

 the following material:

The material will be distributed/published as follows:

Distribution:

Publisher:

Expected distribution/publication date:

Expected length of work (number of images, etc.):

Target market:

 

If you do not solely control copyright in the requested materials, I would appreciate any information you can provide about others to whom I should write, including most recent addresses if available.

 [Optional: Enclosed please find a draft License Agreement for your convenience in responding to this request.]

Sincerely,

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                                       Company Signature

 

___________________                                _______________________

Author's name                                               Name of authorized signatory

 

___________________                                ___________________

                                                                      Title

___________________                                

                                                                       ___________________

___________________                                Company

Address                                            

___________________                                ___________________

Date                                                              Date

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