Health Professions Press | Permissions Request Form

Permissions Request Form

1. What material are you requesting permission to reprint?

Item:
Book title:
Author/editor:
ISBN:
Copyright year:
Page range:
Total # of pages:

2. How will this material be used?

in a text or journal article (go to question 3a.)
on a web site (go to question 3b.)
other (go to question 3c.)

3a. If the material will be reprinted in a text or journal article:

Book/article title:
Author/editor:
Publisher/journal:
Est. print run:
Binding:
Publication date:
Tentative price:

3b. If the material will be reprinted on a web site:

Title:
URL:
Brief description:

Commercial: Nonprofit:

3c. If you selected other above, please provide us with a description of how the material will be used:

Quantity (if applicable):

4. Please provide us with your contact information so that we can send you a response. (Those outside the U.S., please make sure to include your country and city codes when providing us with contact numbers.)

Name:
Title:
Institution:
Address:
City:
State:
Zip code:
Country:
Phone:
Fax:
Email:

(Please note: Your e-mail address will be used only for purposes related to your request. Brookes does not share or sell e-mail addresses — see our privacy policy for details.)

5. What is your deadline for receiving a response?
Please note: Permissions requests typically require up to 4 weeks to process.

6. Any additional information we should know?