Date

Copyright Holder/Publisher [This portion to be filed out by LRC staff]
Street Address
City, State Zip
Attn: Copyrights and Permissions Department

Dear Sir or Madam:

Regarding the following title and information, I would like permission to retain a copy the following material on reserve in the library at St. Charles Community College.

[This portion to be filled out by instructor or requesting department.]
Author or Editor: _________________________________________

Article or Chapter: _________________________________________

Periodical or Book Title: ______________________________________________

For Periodical: Volume #_____ Issue Date: _______ Pages: ______ ISSN: ________

For Book: Copyright date: _______ Pages: ________ ISBN: __________

Number of copies to be placed on reserve: ______________

Time item will remain on reserve until: ____________

The copy will be used exclusively for educational purpose, with no direct or indirect commercial advantage, and will include a notice of copyright for students enrolled in my class.

Thank you for considering my request; I am looking forward to your reply. If you have any questions, contact Gwen Bell, Secretary for Learning Resources at the address listed below, by phone at 636-922-8470, or by email gbell@stchas.edu.

Sincerely,

[Signature of instructor]