Copyright Permission Sample Letter



[this portion to be filled out by LRC staff]
Copyright Holder/Publisher
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 of the following material on reserve in the library at St. Charles Community College. [or permission to make a classroom copies, or permission to scan to a learning management system, etc.]

[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: _______ Page #s: ______ ISSN: ________

For Book: Copyright date: _______ Page #s: ________ ISBN: __________

Number of copies to be placed on reserve or made for classroom use: ______________

Dates the item will be on reserve or used in the classroom: ____________

The copy will be used exclusively for educational purposes 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 look forward to your reply.

If you have any questions, please contact Theresa Flett, reference librarian, by phone at 636-922-8587, or email



Signature of instructor