Reprint permission request form

(For article)

All fields marked with an asterisk (*) are required.
* Company name
* Contact name
  Postal code
* Address
* Phone
* E-mail
* Name of media
* Classification of Media
 book    magazine    leaflet  
 CD-ROM    video    website  
* Projected publication date
* Quantity/circulation
  Number of pages
  Period of use
 From (year)   (month)   (day) 
  ~   to (year)   (month)   (day) 
* Publication
* Title or URL of article you wish to reprint
* Information on how content will be used
  Include photos/graphics?
Yes     No
  If yes, please describe the photo(s)/graphic(s) you wish to use
  Other questions/inquiries