Reprint Permission Request Form
This form should be printed out on your printer, filled out completely and mailed with a check for the specified reprint license fees in US funds. Please make a copy for your records. Permission will be granted either by: (1) signed statment sent via US mail, or (2) digitally signed e-mail sent to your address.
Date _______________________
Name _______________________________________
Phone ________________
Organization Name _____________________________
Address _____________________________________
City _____________________________
State __________ Postal Code ________
Country _________________________________
E-Mail Address _____________________________________
Web Address _____________________________________
I/we hereby request permission to reprint the following articles:
I/we desire to reprint and distribute them in the following manner:
I/we desire to reprint and distribute them for the purpose of:
Enclosed is a check in US Funds for US $______________ for reprint license fees specified in Wilson Internet Services Article Reprint Policies as of _______________ (date).
Signed _______________________________________
Date __________________
Mail a copy of this form and your check to:
Dr. Ralph F. Wilson
Wilson Internet Services
P.O. Box 308
Rocklin, California 95677, USA.
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Do not write below this line
___Approved ___Disapproved
Date_________________ Received $________
Permission for reprinting sent by:
____ Digitally signed e-mail message ____ US Mail
This form was last updated on May 28, 1997.
