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Copyright Permission Request Form

Information About You

Semester & Year   

Instructor's Name   


E-mail address   

Information About The Course

Course Number   

Course Name   


Publication Information

Book/Journal/Newspaper Title

Volume and/or Edition Number
(if None, please type "None" in the blank)


Chapter/Article Name

Additional Information


Copyright Year   

ISBN/ISSN Number   

Month/Day/Year of Publication   

Page Numbers you wish to use:

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The Copy Center Production Manager reserves the right to eliminate or alter any items
not directly related to content that might impede the production of the coursepack.