PERMISSION REQUEST FORM

To:           Name

                  Copyright Permission Requests

                  Publisher

Dear Sir/Madam,

I am preparing a manuscript for the book entitled XXXXXXXXXXXX.  to be published by Springer Science and Business Media, and I request permission to use the material described below from your publication(s):

Publisher:
Author(s):
Full title of the work:
Title of the article:
ISBN/ISSN:
Material to be used:
Page number(s):
Year of publication:

I would be grateful if you would grant permission rights for the original publication, as well as for all revisions or versions, future editions, in any medium such as in its electronic form (offline, online), and for all translations into any foreign language worldwide.

Full acknowledgement will, of course, be given to your publication.

If you agree to this request, please be kind enough to date and sign this form below and return a copy to the address below.

Thank you very much for your assistance.

Date:

Requested by:

<Name>

<Address>

Permission granted as stated above:

Date: