Sample Permission Request Letter

[if sending via postal mail, include a self-addressed, stamped envelope]

[date]

[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.

Sincerely yours,

[your name, position, and contact information]

I do _____ do not _____ grant permission for my work to be used for the purpose stated above.

Name ________________________

Signature _____________________

Date _________________________

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