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Copyright Permission Request Form


Information About You

Semester & Year   

Instructor's Name   

Phone   

E-mail address   


Information About The Course

Course Number   

Course Name   

Section   


Publication Information

Book/Journal/Newspaper Title

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

Author/Editor/Translator

Chapter/Article Name


Additional Information

Publisher   

Copyright Year   

ISBN/ISSN Number   

Month/Day/Year of Publication   


Page Numbers you wish to use:

From          To   

From          To   

From          To   

From          To   

From          To   

From          To   

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