|
_______________________________
Permissions Department
_______________________________
_______________________________
_______________________________
To whom it may concern:
I am requesting your permission to use the following material:
_______________________________________________________________
Title of book/periodical
_______________________________________________________________
Author/Editor
_______________________________________________________________
Title of article, chapter, etc.
Illustration(s)/Table(s)_______________________________________
The material will be cited in the following Lippincott Williams & Wilkins publication:
________________________________________________________________
_____________________________ by _______________________________
Permission is requested on a non-exclusive basis to use this material in this and all subsequent editions of this book or derivatives in English and in foreign translations with distribution rights throughout the world, as well as to include the material in CD-ROM or other electronic format. Proper acknowledgement of title, author, publisher, and copyright date will be given. If the permission of the author is required, please supply address below.
_______________________________________________________________
|
Name |
Address |
City, State, Zip |
Please indicate permission below.
|
Sincerely, |
Permission Granted: |
|
______________________________ |
______________________________ |
|
______________________________ |
Signature __________________________ |
|
Fig/Table ID:_____________________ |
Date _______________________________ |
|