Reprint Permission Request Form
This form should be printed out on your printer, filled out completely and mailed with a check for the specified reprint license fees in US funds. Please make a copy for your records. Permission will be granted either by: (1) signed statment sent via US mail, or (2) digitally signed e-mail sent to your address.
Date _______________________
Name _______________________________________
Phone ________________
Organization Name _____________________________
Address _____________________________________
City _____________________________
State __________ Postal Code ________
Country _________________________________
E-Mail Address _____________________________________
Web Address _____________________________________
I/we hereby request permission to reprint the following articles:
I/we desire to reprint and distribute them in the following manner:
I/we desire to reprint and distribute them for the purpose of:
Enclosed is a check in US Funds for US $______________ for reprint license fees specified in Wilson Internet Services Article Reprint Policies as of _______________ (date).
Signed _______________________________________
Date __________________
Mail a copy of this form and your check to:
Dr. Ralph F. Wilson
Wilson Internet Services
P.O. Box 308
Rocklin, California 95677, USA.
-------------------------------------------------------
Do not write below this line
___Approved ___Disapproved
Date_________________ Received $________
Permission for reprinting sent by:
____ Digitally signed e-mail message ____ US Mail
This form was last updated on May 28, 1997.
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Copyright © 1996-2000 by Ralph F. Wilson, all rights reserved. Text, graphics, and HTML code are protected by US and International Copyright Laws, and may not be copied, reprinted, published, translated, hosted, or otherwise distributed by any means without explicit permission. Trademarks and terms of use.
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