Book Permissions Request Form

Please note before submitting your request please ensure that you have checked the credit line accompanying the material, the Copyright page and or the Acknowledgements pages. Although Wolters Kluwer may have published the book from which you want to reproduce material, we may not be the copyright holder of the material you wish to use.

Name*

First NameLast Name

Company/Organization*

School, Company, Organization Name

Street Address*

Optional: Address (Floor, Building, Apt)

City*

State or Province*

Postal Code*

Country*

E-mail*

wolterskluwers@email.com

Phone Number*

Requestor Type:*

Publisher Name:*

Please describe your role:*

Are you requesting permission from a book or an ACC Chart? *

Number of ACC Charts Requesting*

Anatomical Chart ISBN (13 digit) *

(example: 9781587791000)

Anatomical Chart Name*

Anatomical Chart ISBN (13 digit) *

(example: 9781587791000)

Anatomical Chart Name*

Anatomical Chart ISBN (13 digit) *

(example: 9781587791000)

Anatomical Chart Name*

Anatomical Chart ISBN (13 digit) *

(example: 9781587791000)

Anatomical Chart Name*

Anatomical Chart ISBN (13 digit) *

(example: 9781587791000)

Anatomical Chart Name*

Author*

Title*

Edition*

ISBN (without dashes)*

I would like to use:*

Content Requested [List the specific figures, tables, or text for permission]*

*Please Note*: We cannot grant permission without this information

Do you have additional permissions to request?*

Additional Permissions Needed

Author*

Title*

Edition*

ISBN (without dashes)*

Put N/A if there is no ISBN

Type of Reuse*

Content Requested [List the specific figures, tables, or text for permission]*

*Please Note*: We cannot grant permission without this information

Author*

Title*

Edition*

ISBN (without dashes)*

Put N/A if there is no ISBN

Type of Reuse*

Content Requested [List the specific figures, tables, or text for permission]*

*Please Note*: We cannot grant permission without this information

Author*

Title*

Edition*

ISBN (without dashes)*

Put N/A if there is no ISBN

Type of Reuse*

Content Requested [List the specific figures, tables, or text for permission]*

*Please Note*: We cannot grant permission without this information

Author*

Title*

Edition*

ISBN (without dashes)*

Put N/A if there is no ISBN

Type of Reuse*

Content Requested [List the specific figures, tables, or text for permission]*

*Please Note*: We cannot grant permission without this information

Are you the author of this Wolters Kluwer content?*

How Will Our Content Be Used?*

Book: Author, Title, Edition, Publisher, Publication Date, Price and Page Count.

Journal: Author, Title, Issue, Publisher, Publication Date

CME: Course Name, Dates of the Course, Lecturer/Professor Name, and Number of Particpants for CME

Conference/Meeting: Name of Meeting, Dates for Meeting, and Number Attending/Copies Needed

Course-Pack/Classroom: Course Name, Dates for Course, Teacher/Lecturer Name, and Number of Copies or Students

DVD/CD/USB: Title of DVD or CD and Number of Copies Needed

Government Report: Report Name, How/Where Will it Be Submitted and Number of Copies Needed

Mobile Application: Name of Application, Description of Application and Release Date

Newsmedia: Title of Newspaper/Newsletter, Publisher, Publication Date, and Number of Copies

Photocopy: Number of Copies Needed

Poster: Where Will It Be Displayed, Duration of Posting, and Number of Copies Needed

Thesis/Dissertation: Title of Thesis, Quantity of Copies Needed, and Website(s) Thesis Will Be Posted

TV/Documentary/Film: Name of TV Show/Documentary/Film, How Our Material Will be Used, Broadcast Date and Location.

Website: Website Address, Website Description and Duration of Posting

Please provide description of your proposed use for our material

Please Provide:*

PLEASE NOTE THAT IN ORDER FOR YOUR REQUEST TO BE CONSIDERED:

Article is required to have been accepted for publication in a journal
The journal cannot be published under an Open Access License

For the new project, has the article been accepted for publication?*

YesNo

For the new project, will the journal be published under an Open Access (OA) License?

YesNo

What is the Creative Commons License?

Please Note: If the new article is being published as Open Access, please indicate above what the CC License type will be. Please reference this link: Creative Commons Licenses

Where do you attend university?*

Will the Wolters Kluwer/LWW Content be shown on camera?

YesNo

Will this be posted to your university website?*

YesNo

Is the website password protected*

YesNo

Will the website be password protected*

YesNo

Have the books been adopted for the course?*

YesNo

I am receiving sponsorship*

Additional languages (other than English)*

YesNo

Number of Languages*

Language(s) needed*

(This does not include English which is standard)

Format*

Print and ElectronicPrint OnlyElectronic Only

Notes/Comments

**PLEASE NOTE**
Form submitted with incomplete/missing information will delay your permission process.
Thank You.

Books Permission Request Form

Wolters Kluwer Product Information (Book or Anatomical Charts)

Intended Use