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]