Wiley::Educational Request Form

First Name:

Last Name:

Street Address:

City:

State/Province:

Zip/Postal Code:

Country:

Contact Phone Number:

Fax:

E-mail Address:

Your Reference Number (if any):

Wiley product/title from which you'd like to photocopy:

Is this title a book or a journal?

If this title is a book, please provide the following:

Book's Primary Author or Editor:

Book's ISBN:

In-stock Date (if known):

If this title is a journal, please provide the following:

Journal Month:

Journal Year:

Journal Volume:

Journal Issue Number:

Specific pages or range of pages or figure numbers you wish to copy:

Maximum estimate of the number of copies you'll need:

Will the material be posted on a website or intranet site?

What is the url where the material would be located?

Is the web site where the material will be posted password protected, or is access to the site limited in any way?

How many users would have access?

How long will the material be posted (not to exceed a two year limit)?

From:

(dd/mm/yyyy)

To:

(dd/mm/yyyy)

Name of Your University or Institution:

Course Name and Number:

Term:

Instructor's Name:

Is the book the required textbook for the class?

Yes No

Are you a Wiley author?

Yes No

Please indicate any unusual circumstances regarding this request (such as you are the author of the requested material)

(Please note: Response will be sent via fax or mail, not by e-mail.)

John Wiley & Sons, Inc.
and Wiley-Liss, Inc.
Permissions Department
111 River Street
Hoboken, NJ 07030-5774
USA
0101-201-748-6011 (Telephone)
0101-201-748-6008 (Facsimile)

John Wiley & Sons, Ltd.
Permissions Department
The Atrium
Southern Gate
Chichester
West Sussex PO19 8SQ
United Kingdom
44-1243-843356 (Telephone)
44-1243-770620 (Fascimile)
permreq@wiley.co.uk

Wiley-VCH Publishers, Inc.
Rights and Permissions
P.O. Box 10 11 61
D-69451, Weinheim
GERMANY
49-6201-606-280 (Telephone)
49-6201-606-215 (Telephone)
49-6201-606-332 (Fascimile)
rights@vchgroup.de