[this portion to be filled out by LRC staff]
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 firstname.lastname@example.org.
Signature of instructor