[if sending via postal mail, include a self-addressed, stamped envelope]
[copyright owner's or agent's name and address]
Dear [copyright owner or agent]:
I am writing to ask your permission to use [give full citation of the work] for the purpose of [describe the intended use in sufficient detail].
Please complete and return this form to me at your earliest convenience. Thank you very much for your consideration.
[your name, position, and contact information]
I do _____ do not _____ grant permission for my work to be used for the purpose stated above.