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Permission Request Form

Please use this form to submit your request.

Personal Details

*Title

*First Name(s)

*Surname

*Email

*Telephone

Fax

Occupation

*Preferred job title

Company name

*Address

Address line 2

*Town/City

*County

*Country

*Postcode

Permission Requests

*Title of publication

*Edition

Author (if available)

* Brief description of your request

* Specific list of materials you wish to reproduce. (i.e. pages, tables, pictures, etc...) (Note: We may contact you for copies of the specific materials)

* Number of subjects/administrations or copies needed per year

Name of party responsible for tracking reproductions and payment of fees

Inclusive Dates

Adaptation and/or format changes required? (i.e., computer-adaptation, scannable format, 3-part paper)

Is this request for permission to translate?

Yes

If yes, please also complete additional Section II.

Is this request for permission to use materials in a book?

Yes

If yes, please also complete additional Section III.

Permission Requests - Section II (Translation Information)

For request to translate, please complete the following additional information:

Name of Language

Purpose of Translation

Name and qualifications of the individual(s) who will be conducting the translations:

Name and qualifications of a separate individual who will back-translate the materials for our review:

Qualifications of all individuals who will use the translated materials:

Where will the test be used?

How do you intend to ensure test security?

How do you intend to track the number of reproductions for reporting to us for billing purposes?

Additional Comments

Permission Requests - Section III (Publishing Information)

If for a book, please provide the following additional information about your product:

Title of your publication

Type of media (i.e., CD-ROM, print, etc...)

Publisher

Approximate date of publication

Additional Comments

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