Professional Documents
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Permissions Request Form: Material To Be Reproduced
Permissions Request Form: Material To Be Reproduced
Permissions Request Form: Material To Be Reproduced
Request Form
(author name) is seeking non-exclusive permission to reproduce the following copyrighted item/s
Material to be reproduced:
Journal, Series,
Serial or Book Title
Volume Title
Chapter/Article Title
Author/s
No. of items to be
reproduced Year of Publication
Type of Item to be
Figure Table Illustration Excerpt
reproduced
Name of Item
Page Number of Excerpt word count
Item (if applicable)
Excerpt text
(if applicable)
Rights Required:
Print and Electronic – All of the above able to include sublicensing, without charge, of publication or transcription in Braille,
large-type editions, or recordings for the blind and other special editions for use by the physically handicapped by
approved non-profit organisations, only if such edition is neither sold nor rented for a fee
Worldwide English Language Rights only
To use the material for the life of the work (i.e. there should be no time restrictions on the reuse of material, e.g. one-year
licence granted)
Details of Forthcoming Publication by Emerald Group Publishing Limited:
Journal, Series,
Serial or Book Title
Journal or Series
Editor/s
Volume Title and
Number
(if applicable)
Name
Position
Signature
(either hand-written or
insert a scanned
signature)
Date
Name
Address
Signature
(either hand-written or
insert a scanned
signature)
Date