Request Form for Permission to Reprint
REQUEST FOR PERMISSION TO REPRINT
Please fill out this form for each request and email to: firstname.lastname@example.org
I am requesting rights to reprint or reproduce the following material copyrighted by Barcelona Publishers: for worldwide distribution and for all reprints and revisions of my book or article.
Your book or article:
Title of chapter or article:
Title of book or journal:
Language of publication:
Total # pages of article or book:
# Copies to be printed:
Price per copy:
Barcelona material to be reprinted or reproduced:
Title of Barcelona Book:
Material to be reprinted or reproduced:
Text: From page # To page#
Beginning at the phrase:
Ending at the phrase:
Total Number of words:
Your Name and Mailing Address:
City State Zip
_____Barcelona Publishers grants permission as specified above at no cost.
_____Barcelona Publishers grants permission as specified above for the cost of_______
_____Barcelona Publishers does not grant permission as specified above.
NOTE: If permission is granted, the following acknowledgment must be made in the anticipated publication:
Reproduced by permission of Barcelona Publishers.
Signature of officer:
Kenneth Bruscia Date