Sample Permission Request Form

Date:_______________________ Wiley Permission #____________________
To: Wiley manuscript page_________________
  or
  Wiley figure #________________________

I am preparing a manuscript to be published by John Wiley & Sons, Inc.:

Author/tentative title:_____________________________________________________________________

I request your permission to include the following material in this and all subsequent editions of the
above-referenced book, in all media of expression now known or later developed and in all foreign 
language translations and other derivative works published or prepared by John Wiley & Sons, Inc.
or its licensees, for distribution throughout the world, and also in versions made by nonprofit
organizations for use by blind or physically handicapped persons.  Appropriate credit will be given
as provided below.

Authour(s) and/or editor(s):_________________________________________________________________

Title of book or periodical:_________________________________________________________________

Title of selection:________________________________________________________________________

Copyright date:__________________________________________________________________________

From page__________, line_________, beginning with the words__________________________________

To page____________, line_________, ending with the words____________________________________

Figure #________________ on page ______________ Table #______________ on page________________
(if necessary, attach continuation sheets)

Please indicate agreement by signing and returning the enclosed copy of this letter to me.  In signing, you warrant that 
you are the sole owner of the rights granted and that your material does not infringe upon the copyright or other rights 
of anyone.  If you do not control these rights, I would appreciate your letter letting me know to whom I should 
apply.

Thank you,

__________________________________________
Name

__________________________________________

__________________________________________

__________________________________________

__________________________________________
Requester's return address






Agreed to and accepted:

by:_________________________________________________________________________
	(signature)				(title)					(date)
Credit and/or copyright notice:___________________________________________________