Tuesday, May 26, 2009

Bellingham Technical College

3028 Lindbergh Avenue

Bellingham, WA 98225

Phone 360.752.7000

Fax 360.676.2798

Rights holder name

Rights holder address

Rights holder city, state, zip

Dear Rights holder/permissions editor/personal name (if known):

I am an instructor at the Bellingham Technical College. I teach in the Department/Program here. I am in the process of creating Describe project/classroom use here (if you are making copies for student use, etc.). I have found the following work: Name of work under copyright here, which I believe you hold the copyright to. This work has important educational value that my students could benefit from. I would like your permission to include the following material from Name of work under copyright in Name of your project.

Book/Title: title of book here	Copyright Year: copyright year here
Author: author name here	Page # from: page # here	to: page # here	Chapter(s): Ch. here
Publisher: publisher name here	Photograph/ Page #: photograph/page # here
ISBN/ISSN: ISBN/ISSN number here	Illustration & Figure #: Illustration & figure # here
Edition: edition here	# of copies or units to be reproduced: # copies/units here
Format will be distributed in the following format(s):
Print: [ ]	CD-Rom: [ ]	Internet: [ ]	Intranet: [ ]	Campus: [ ]	Network: [ ]
Closed Circuit Broadcast: [ ]	Satellite Transmission: [ ]	Other: Please explain here

Describe how the project and material will be used in detail here. If you are requesting to have the information posted to a website, be sure to include the URL and note whether or not it is password protected. It will be accessible to describe users and number of users here.

If you are not the copyright holder on the above mentioned materials, 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.

I would greatly appreciate your consent to my request. If you require additional information, please do not hesitate to contact me. I can be reached at:

First & last name

Mailing address

City, State, ZIP

Phone number

Email address

A duplicate copy of this request is being sent for your records. If you agree to the terms described above, please sign the release form below and send me one copy with the self-addressed stamped return envelope I have provided.

Sincerely,

Typed name here

Permission granted for the use of the material described above:

Agreed to:	Name & Title:

Company/Affiliation:	Date: