Dear [copyright holder]:
[The UW-_______] requests permission to copy and use the following material:
Edition to be duplicated and year of copyright:
Material to be used: [i.e., amount, page numbers, chapters of the material]:
Period of intended use:
Method of reproduction:
Nature and purpose of use [teaching, research, etc.]:
Form of distribution:
Whether or not the material will be sold:
Number of copies:
Please advise me not later than_______, whether permission is denied, granted, or conditioned on any specific additional terms.
Thank you for your assistance.
[Authorized institutional representative]