Harcourt Standard Permissions Request Form

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Standard Request Form

PLEASE NOTE: an asterisk(*) indicates required information

Requestor's Information

Honorific *
First Name *
Last Name *
Address 1 *
Address 2
Address 3
City *
State/Province *
Postal Code *
Country *
Phone
Fax
E-Mail

Information About OUR Work

Harcourt Division
Series Title *
Component Title
Edition
Grade or Level
Volume
Number
ISBN
Author or Editor *

Describe the exact material you are using including opening and closing page numbers, figure numbers and titles of selections from our work. A selection could be a poem, chapter, essay, introduction, etc. from our work. *

Information About YOUR Work

Please enter your Publisher Name *

Have you used this same material in a previous edition of your work?
If so, please provide the request ID or reference of the previous grant.

Complete title of your work in which our material will appear

Title *

Author or Editor *

Please indicate how you wish to use this material; as a chapter heading, epigraph, or in context.

Chapter Heading Epigraph In Context

Your work is a (select all that apply) *

Website

Textbook

Trade

Scholarly
Other

Estimated PRICE of your work *

Hardcover Softcover Other

Estimated NUMBER of copies that will be printed IN ALL PRINTINGS for the life of the edition (example: 20,000, 50,000 100,000 copies) *

Hardcover Softcover Other

Estimated publication DATE *

Hardcover Softcover Other

Term of license requested years *

Hardcover (1-13 years) Softcover (1-13 years) Other (1-13 years)

Market information (provide the market in which your work will be distributed) *

If other selected please describe

Language (provide the language in which your work will be printed) *

If other selected please describe

Web Publishing

If our material is going to be posted on a website...

What is your web address?
Is your site password protected?	Yes No
Estimated date our work will appear on your site

Additional Comments