PERMISSIONS

Pauline Books and Media Permissions Request Form

 

Date of Submission: _______________________________________________

 

Information Pertaining to Our Book:

 

Title:  ___________________________________________________________

 

Author:  _________________________________________________________

 

Copyright year: __________________________________

 

ISBN: __________________________________________

 

Material you want to use (please specify page number and/or approximate number of words):

 

__________________________________________________________________________________

 

A photocopy of the material in context must be provided if requesting to publish the material in a new project.

 

Information Regarding Your Project:

 

Title: ____________________________________________________________

 

Author: __________________________________________________________

 

Publisher:  _______________________________________________________

 

Territory needed: ______________________________________

 

Print run/circulation: ___________________________________

 

Price: _______________________________________________

 

Publication date:    ____________________________________

 

Number of pages of your book: __________________________

 

Format (Hardcover/Softcover/E-book): ____________________

Requester Information:

 

Name: __________________________________________________________

 

Position: ________________________________________________________

 

Company: _______________________________________________________

 

Address: ________________________________________________________

 

City:  ___________________________________________________________

 

State:  __________________________________________________________

 

Zip Code: ________________________________________________________

 

Phone:  _________________________________________________________

 

Fax:   ___________________________________________________________

 

E-mail: __________________________________________________________

 

If mailing your request, please allow 3-5 weeks for a response.  If emailing your request, you may expect a response to your inquiry within 3 business working days.

 

A self-addressed stamped envelope would be appreciated.