Template: Request Permission to Reproduce Copyrighted Material

On behalf of the Regents of the University of California, I ___(Fill in name)____ am requesting your permission to (check all that apply):

_____ reprint

_____ photocopy

_____ digitize

_____ incorporate into:

_____ course materials

_____ online course materials

_____ a website publication

_____ a streaming online video (through YouTube or another

source)

the following material:

Author:

Title:

Vol: Issue:

Page #(s): Figure/ Table #(s):Image #(s:)

Minutes:

The material will be distributed/published as follows:

Purpose: Not-for-profit, educational [fill in if other]

Format:

Number of Copies:

Distribution/Access:

AR rev 4/5/10

PERMISSION GRANTED:

I, _________________________, have the authority to grant the permission requested herein and I hereby grant _____________________ permission to use the above referenced material in the manner described.

The credit line should read:

______________________ __________ ______________________ __________ ______________

______________________ __________ ______________________ __________ ______________

By: ________________________________

Title:_______________________________

Address:_________________________________________________________________

______________________ ______________ Date

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