[Letterhead stationery or return address] [Date] [Name and address or addressee] Dear :____________________ [Optional beginning sentence: This letter will confirm our recent telephone conversation.] I am completing a doctoral dissertation at
_____________ University entitled "_____________ ." I would like your permission to reprint in my dissertation excerpts from the following: [Insert full citation and description of the original work] The excerpts to be reproduced are: [insert detailed explanation or attach copy] The requested permission extends to any future revisions and editions of my dissertation, including non-exclusive world rights in all languages, and to the prospective publications of my dissertation by UMI Company. These rights will in no way restrict republication of the materials in any other form by you or others authorized by you. Your signing of this letter will also confirm that you own [or your company owns] the copyright to the above-described material. If these arrangements meet with your approval, please sign this letter where indicated below and return it to me in the enclosed return envelope. Thank you very much. Sincerely, [Your name and signature] PERMISSION GRANTED FOR THE USE REQUESTED ABOVE: _______________________________________
[Type name of addressee below signature line] Date: _____________________
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