Republication/Electronic Request Form


First Name:

Last Name:
Name of Company or Organization:

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 reprint: (For journals, please provide the journal name and not the individual article title)



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:


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

Journal Month:

Journal Year:

Journal Volume:

Journal Issue Number:

Specific pages numbers, figures/tables, and/or total word count you wish to reproduce:

Maximum print run estimate:

Your Publisher:

Title of Your Work:

Projected Publication Date:

Format of Your Work: (Check all that apply)

		Print:

		CD-ROM:

		E-Book:
		Reader Type (Adobe Acrobat or Microsoft):

		WWW:

		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)

		Intranet:

		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?
		From:		(dd/mm/yyyy)
		To:		(dd/mm/yyyy)

		Software Program: (i.e. Powerpoint, database, disk)

		Other (Please Specify):



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

John Wiley & Sons, Inc.
and Wiley-Liss, Inc.
Permissions Department
111 River Street
Hoboken, NJ 07030-5774
USA
PermissionsUS@wiley.com

Wiley-Blackwell, Inc.
John Wiley & Sons, Ltd.
Permissions Department
The Atrium
Southern Gate
Chichester
West Sussex PO19 8SQ
United Kingdom
PermissionsUK@wiley.com

Wiley-VCH Publishers, Inc.
Rights and Permissions
P.O. Box 10 11 61
D-69451, Weinheim
GERMANY
rights@wiley-vch.de

Republication/Electronic Request Form

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