Contract for Permissions
Your Contact Information
Name:
Email:
Address:
Phone:
City:
Fax:
State:
Zip:
Tittle of poem(s) selected:
Title of book(s) from which Poem is selected:
Author:
If this request is for inclusion in book form, please fill out the following information:
Title of Work:
Price:
Type of Work: (e.g., anthology)
Binding:
Author / Editor:
Publication Date:
Publisher:
If you are without a publisher at this point, please re-apply for permission when the publisher of your manuscript has been named.
Print Run:
Rights: (e.g., North American, World, etc.)
If this request is for broadcast or website posting please fill out the following relevant information:
Type of Show:
Call Letters:
Type of Broadcast:
Web Address:
Name of Host:
Broadcast Date:
Company:
If this request is for a student packet, please fill out the following information:
Number of pages to be photocopied:
Instructor:
Number of packets to be printed:
Start of Term:
College or University:
Course Number:
For other kinds of permission requests, or to provide more details about
information submitted above:
