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
.

 

-------------------------------------------------------
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.

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