Request For Permission To Reproduce Images

Document Overview

This is a fillable request for permission to reproduce images. Click any blank field in the document below, type your information, and your entries will autosave in your browser. Use the toolbar at the top to print, save as PDF, or download a completed copy. Below the form, you'll find a guide to using this document, common mistakes to avoid, and answers to the questions we hear most often about request for permission to reproduce images.

RE:  Request for Permission to Reproduce Image(s)

Dear Contact Name :

Reproduce the image / Publish the image / Both reproduce and publish the image

I am writing to request permission to Image Goal described below the "Image(s)":

• Artist: Artist's name
• Title: Title of work
• Date: Date
• Medium: Art medium
• Dimensions: Size
• Yes / No ID Number: ID number Yes / No
• Artist: Artist's name
• Title: Title of work
• Date: Date
• Medium: Art medium
• Dimensions: Size
• Yes / No ID Number: ID number Yes / No
• Artist: Artist's name
• Title: Title of work
• Date: Date
• Medium: Art medium
• Dimensions: Size
• Yes / No ID Number: ID number Yes / No
• Artist: Artist's name
• Title: Title of work
• Date: Date
• Medium: Art medium
• Dimensions: Size
• Yes / No ID Number: ID number

Yes / No Color print / Black and white print / Color transparency

The Image(s) will be used as follows: Description .

Yes / No

The Image(s) will not be used in a seminar or other educational activity.

Yes / No
Volume / Issue / Edition

I hereby request nonexclusive worldwide rights, for this Image Desc Image Desc Image Desc Description only. If you are not the copyright holder, or if permissions from other sources are needed to obtain worldwide rights, including rights in and to the reproducible copies or prints of the Image(s), please let me know and indicate the person or company to which such requests should be directed. I acknowledge that submission of this request does not constitute permission, and that any use of any copyrighted images owned by the copyright holder is unauthorized unless and until I have received a signed letter of permission or agreement. I further acknowledge that if any usage or administrative fees are assessed by the copyright holder, a signed letter of permission or agreement may be withheld until those fees are paid.