[Date]

[Letterhead or Return Address]

[Rights holder Name and Address]

 

Dear _________________:
The Office of Professional Development at Indiana University Purdue University at Indianapolis (IUPUI) and faculty member _____________, professor ____________________, would like to use the following material on a class web site to supplement my instruction of this class:

[Citation with source information]

This request is for the following course:

[Course Name]

This is an online course that can only be accessed only by IUPUI students enrolled in the class. All students will be required to purchase your textbook. We would like to post selected materials from the [source] onto the password-protected server available only to the students that have enrolled in the class and have purchased the textbook. Each use of such work will be properly cited to its source.

If you do not control the copyright on all of the above mentioned material, I would appreciate any contact information you can give me regarding the proper rights holder(s), including current address(es). Otherwise, your permission confirms that you hold the right to grant the permission requested here.

While the use of the material described above may be a fair use, we would greatly appreciate your consent to our request. If you require any additional information, please do not hesitate to contact me. I can be reached at:

[Your contact information]

A duplicate copy of this request has been provided for your records. If you agree with the terms as described above, please sign the release form below and send one copy with the self-addressed return envelope I have provided.
Sincerely,

[Signature]

[Your typed name]

---

Permission granted for the use of the material as described above:

Agreed to: __________________________

Name & Title: _______________________

Company/Affiliation: __________________

Date: ______________________________

Page Last Updated: August 15, 2003