Date _________________________________________

Permissions Department
The Wildlife Protection Network
PO Box 153
Gladwyne, PA 19035

Dear Madam:

May I have permission to copy the following:

Citation (Cite your source in full, listing author, title, edition, date published, and specific pages, specific URL's or other media to be copied)

 

 

 

Copying format (photocopies, slides, computer diskettes, etc.)

 

 

 

Number of copies __________________________________

Cost (mention non-profit educational use, free distribution, etc.)

 

Distribution method (classroom handouts, coursebook, posting on school web page, online class, distance learning class, webquest, personal web page, technology component for class project, university site page etc.)

 

 

Intended use (briefly describe the intended use of the material you are requesting permission to use)

 

 

Date of use _________________________________________

If permission is granted, I will fully acknowledge the author and publisher by properly crediting the source. Please sign this form and return to me.

Sincerely,

Your Signature _________________________________________

Print your name _______________________________________

Your title _________________________________________

School/Business _________________________________________

School/Business Address

_________________________________________

_________________________________________

_________________________________________

_________________________________________

Telephone_________________________________________

e-mail _________________________________________

fax number _________________________________________

 

The Wildlife Protection Network Official Use:

Permission granted____________________________

Date________________________________________

Conditions (if any)_____________________________

Signature____________________________________

Title_________________________________________

*Print this out, fill it in, and mail it back.
*Include Addressed and Stamped envelope for your
Returned Permission Form Request, or it will not be sent back.