PERMISSIONS CHECKLIST

First name, last name:
Company:
Address:
Phone number:
E-mail:

Title and Edition number:

Author:

Publisher:

ISBN:

Languages needed:

Total circulation, including any ancillaries:

Distribution area:

Usage (textbook, e-book, website, workbook, teacher’s guide, etc.):

File number or description and credit line:

Size used on page:

Placement in text (in text, opener, cover, etc.):

“Bill To” Contact if other than above:

“Send To” Contact (e-mail address) if other than above: