This example contemplates a book, although it can be
adapted for other media.
Dear Sir/Madam
On [date], I intend to publish a book entitled
[title of book]. Within the text of that book I would like
to use the following material in English (and in Braille and sound recording for the blind).
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Author:
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[Name]
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Publication:
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[Book Title]
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Chapter:
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[Chapter number and title]
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Page No(s):
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[Pages]
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Word count:
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[Number of words]
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[Option 1: I wish to distribute the publication
in the world market. The proposed print run will be
approximately [number] copies. I also intend to make the chapter including the above material
available on an intranet site, which will be password protected. Login details to the password
protected site will be provided to no more than [number] students and [number] of my colleagues in
the [Department] of the University of Cambridge.]
[Option 2: I request your permission to reproduce
or, if it is necessary, to redraw or modify the
material listed above in this and all subsequent editions of [title of book], its ancillaries, and other
derivative works, in any form or medium, whether now known or hereafter developed, in all
languated, for distribution throughout the world.]
I enclose a photocopy of the material to be used.
I hope that you will be able to grant me permission to
use this material for which full
acknowledgement of the original source will be made. If you do not control the rights to the
material mentioned above, I would be most grateful for the name and address of the person to
whom requests should be directed?
I appreciate your co-operating in making this material
available and would ask you to kindly return
this complete document duly signed.
Yours faithfully
[Sign]
Permission is hereby granted for the use of the material
described above.
Signed ______________________________________
Title ________________________________________
Company / Publisher ____________________________
Date ________________________________________
