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:
	Is this title a book or a journal?    Book 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 or range of pages of text and/or figure/table numbers you wish to reproduce: [If the number of figures exceeds 5 figures and/or 300 words of text per requested work, or if you're adapting (changing) our material, please fax (201-748-6008) or mail (Permissions Dept., John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030-5774) copies of the figures (and your adapted versions if applicable) with this request.]

Maximum print run estimate:
Your Publisher:
Title of Your Work:
Projected Publication Date:
Format of Your Work:

		Print:
		CD-ROM:
		What is the size of the print run (in number of copies)?
		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?		No Yes
		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?		No Yes
		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)
		What is the size of the print run (in number of copies)?

	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 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 s D-69451, Weinheim GERMANY 49-6201-606-280 (Telephone) 49-6201-606-332 (Fascimile) rights@vchgroup.de