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Sample Permission Letter

To: Mr. John Doe
Copyright and Permissions Officer
Random House Publishers
332 Fifth Avenue
New York, New York 20021

From: Ms. Jane Doe
Library Director
Mabee Library
Washburn University
1700 SW College
Topeka, Kansas 66621

Date: December 4, 2001

RE: Permission to duplicate a book chapter

Dear Mr. Doe:

This letter will confirm our recent telephone conversation. I request permission to reprint the following chapter in a coursepack for ED 565, Introduction to Educational Research, for use during the Spring 2002 semester.

Author(s): Robert Jackson
Title (edition, volume): Studies in Modern Education, 3rd ed.
Copyright date: 1999
Material to be duplicated (chapter, pages): pages 45-67, Chapter 3 - "Multiple Intelligences in the Classroom"
Number of copies: 23
Form of distribution: supplied to students free of charge for classroom use
Type of reprint: photocopy

A photocopy of the material is enclosed. Unless you indicate otherwise, the material will be accompanied by the following credit line and copyright notice:

Copyright ©1999 by Robert Jackson. Reprinted with permission from publisher.
All rights reserved by the original copyright holder.

Thank you for your prompt consideration of this request. Enclosed is a stamped, self-addressed envelope to send back the signed permission form.


[your signature]


_ Permission is granted for the use requested above.

_ Permission is not granted for the use requested above, for the following reason(s):

_________________________ _________________________

Signature Date

(Name, Title)
(Fax # / Phone # / Email)

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Washburn University School Of Law

Washburn University prohibits discrimination on the basis of race, color, religion, age, national origin, ancestry, disability, sex, sexual orientation, gender identity, genetic information, veteran status, or marital or parental status. The following person has been designated to handle inquiries regarding the non-discrimination policies: Dr. Pamela Foster, Equal Opportunity Director/Title IX Coordinator, Washburn University, 1700 SW College Ave, Topeka, Kansas 66621, 785.670.1509,

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