Third-Party Copyright Permission Form
1. Requestor Information
Name
Organization / Institution
Email
2. Work Information
Title of Third-Party Work
Author/Creator
Description of Material
Publisher / Source
Date of Publication
Intended Use (e.g., thesis, website, presentation)
3. Rights Holder Permission
Name of Rights Holder / Copyright Owner
Contact Information
Permission Granted (Please specify the scope, e.g., one-time, perpetual, non-exclusive, etc.)
4. Additional Terms or Conditions
Rights Holder Signature
Date
Requestor Signature
Date