REQUEST FOR PERMISSION: LIBRARY RESERVES



To:
Date:

I am writing to obtain permission to duplicate and place on class reserve at the Linn-Benton Community College Library the following material(s). The Copyright Clearance Center has advised us that we must contact the copyright holder directly to obtain this permission.

The material will be used for educational purposes only and not for profit.

Journal or book title:


Book author or editor:

Journal issue or book edition:

Copyright or publication date:

ISBN for books/ISSN for magazines and journals:

Author's full name:

Article title or book chapter:


Pages:

Name and number of academic course:

Expected class size:

Term / year course is taught:

Item may be assigned in future semesters: _____ Yes ______ No

Name of instructor:

If you are not the copyright holder or do not have authority to grant this request, I would appreciate any information you can provide concerning the current copyright holder. Please specify here any additional source from whom permission must be obtained. Thank you for your prompt consideration of this request. Please apprise me of your decision at your earliest convenience.

Sincerely,


Requester's Name:
Address:


Fax:
E-mail:

FOR USE OF COPYRIGHT HOLDER:
Subject to the access restrictions noted above, the above request is approved for reserve use for: _____Current Term
_____Current Term and Future Terms
_____Other (Please Specify)

Approved by:
Date: