Publishers Permission Request Form

Publishers Permission Request Form

Name

First Name

Last Name

Company/Organization

Street Address

Optional: Address (Floor, Building, Apt)

City

State

Postal Code

Country

Requestor Type

What publication are you seeking copyright permissions for?

Please provide a brief description of how you plan to use The ASAM Criteria in your publication?

What material are you seeking copyright permissions for? (Please provide hyperlink if from website location)

Work in which the material will be used? (title of publication)

Credit line for material requested? (includes identification of specific graphics & text)

What permission rights are you requesting ?

New code

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