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BOOK PERMISSION REQUEST FORM
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Date:..................................
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Copyright Owner’s Address:...........................................
(détenteur des droits d'auteur)
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Dear Sir or Madam,
I am preparing a book / a chapter in a book entitled ...........................................
which will be published by John Libbey Eurotext Ltd, France in (1st, 2nd, 3rd, 4th quarter of year).
I am seeking your non-exclusive permission to reproduce or, if necessary, to redraw or modify the material listed
below in this and in all subsequent editions of the book, in all languages, in other derivative works published by
John Libbey Eurotext and in all media of expression now known or later developed, for distribution throughout
the world. Full credit will be given to the original source.
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FIGURE or TABLE
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ORIGINAL JOURNAL OR BOOK TITLE: ............................................................................
AUTHOR: ............................................................................
VOLUME, EDITION, PAGE N° & FIGURE N°: ............................................................................
ARTICLE or CHAPTER TITLE: ............................................................................
PUBLISHER & YEAR OF ©: ........................................................................................................
I AM THE AUTHOR OF THE ORIGINAL MATERIAL:  Yes No
If you agree to the above request, please sign this form and return to me by e-mail or post.
If you do not control the rights for the material for which I am hereby applying permission to reproduce, would
you please kindly supply me with the name and the address of the person to whom my request should be directed.
With thanks in advance.
Author name: .....................................................................................
E-mail: .............................................................................................................
Address: ........................................................................................................................................................
........................................................................................................................................................
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AGREED TO AND ACCEPTED:
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Name: ........................................................
Company: :........................................................
Date : ............................
Signature : ................................
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