Permission Request Form
Name of requestor:
*
First Name
Last Name
Email:
*
example@example.com
Name of publisher:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Requested ASA copyrighted material (include link to resource):
*
If you are requesting an abstract, please provide the following information: Abstract author, title, year, and location.
Publication Information
Title of the publication:
*
Title of the chapter/article:
*
Approximate publication date:
*
Format/number of copies:
*
Indicate if you are requesting permission ‘as is’ or for a modification. In general, modifications are not approved.
*
Indicate if the material will be translated. If yes, please indicate who will translate the material. ASA does not provide translation services.
*
Deadline date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: