Request for Permission and Agreement Granting Permission to

Distribute Copyrighted Material for Fundraisers

To: ______________________________
(Name of copyright owner)

(Address of copyright owner)

The undersigned,_________________________(name of proposed user), of_______________

__________________________________________________________________________(street
address, city, state, zip code), hereby requests permission to distribute your publications entitled

(title of publication) the following material:

(Description of material including details such as page numbers,

paragraphs, and approximate number of words)

This material is to appear without change as.

The undersigned agrees to give full credit to________________________(name of author) in

the following form on the copyright page or the first page on which the selection appears:
(words of credit)_____________________________________________________________________.
The undersigned promises and agrees to restrict the use of the selections herein described to
the Book described above and to pay you on or before the date of publication the fee of
$_____________.

The undersigned further promises and agrees to forward to you one copy of the Book on or
before publication. If the Book is allowed to go out of print, all rights granted in this agreement
automatically revert to you, and all permissions are terminated, except that the rights extend to
revised editions where changes in content do not exceed______________(fraction) of the original
text.

Witness my signature this_______________________(date).

Printed Name of Requesting Party

Signature of Requesting Party

 The undersigned_____________________________(Name of Copyright Owner) does
hereby grant my permission on the terms set forth above.

Witness my signature this_____________________(date).

Printed Name of Owner

Signature of Owner