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CoursePack Permission Forms

Sample Coursepack Request Form

Below is a sample coursepack permission request form prepared by the Association of Academic Publishers.

Coursepack Permission Request Form
(Association of Academic Publishers)


Publisher Contact: ________________________________________

Publisher: ________________________________________

Fax Number: ________________________________________

Date of Request: ________________________________________


Your Name: ________________________________________

Department: ________________________________________

School name: ________________________________________

Address: ________________________________________

City: ________________________________________

State: ________________________________________

Zip code: ________________________________________

Phone #: ________________________________________

Fax #: ________________________________________

Course name and number: ________________________________________

Number of copies needed: ________________________________________

Instructor: ________________________________________

Semester and year: ________________________________________

ISBN/ISSN number: ________________________________________

Book or journal title: ________________________________________

Author: ________________________________________

Translator: ________________________________________

Editor: ________________________________________

Edition: ________________________________________

Volume: ________________________________________

Copyright year: ________________________________________

Publication year: ________________________________________

Chapter/article title: ________________________________________

Chapter/article author: ________________________________________

Page numbers: ________________________________________

Total pages: ________________________________________

Is it an out-of-print work? ________________________________________

Have you included a copy of the material with this request? ________________________________________

Are you the author? ________________________________________

Permission is requested for use during one term only. ________________________________________



Coursepack Permission Agreement

Ordinarily, when you create your own coursepack, you will be seeking permission to photocopy the material. You should always obtain written permission from the copyright owner for this. Use the agreement below for this purpose.

In the section entitled "Number of Copies & Assembly," indicate the number of copies to be produced for the class and check the box that indicates how the coursepack will be assembled. Coursepack agreements are almost always limited to one semester and to one institution. Unlike the non-negotiable coursepack agreements provided by clearance companies, you can modify this agreement if you wish to negotiate a multi-term agreement.

Coursepack Permission Agreement

________________________________________ ("Licensor")

________________________________________ ("User")

Department: ________________________________________

School Name: ________________________________________

Course name and number: ________________________________________ ( "the Course").

Date when Course starts: ________________________________________ (the "Course date").


Licensor authorizes User to photocopy the Selection, as defined below, for purposes of creating a photocopy anthology (the "Coursepack") for sale or distribution to students and academic customers in the Course.

Number of Copies & Assembly

_______ copies of the Coursepack shall be assembled and distributed for the Course:

___ by User

___ by on-campus bookstores or copy centers, or

___ by off-campus copy shops.


Number of pages (or actual page numbers) to be used ________________________________________.

The permission granted in this Agreement is limited to the Course and institution listed above and to be used for one semester only. Any further rights must be negotiated separately.

Material for Which Permission Is Sought

Title of text or artwork: ________________________________________ (the "Selection").

Author: ________________________________________.

Source publication (or product from which it came): ________________________________________.

If from a periodical, the ISSN, volume, issue and date. If from a book, the ISBN: ______________________.

If from the Internet, the entire URL address: ________________________________________.


A standard credit line including User's name will appear where the Selection is used. If you have a special credit line you would prefer, indicate it here: ________________________________________.


User shall pay a fee of $_______ to Licensor at the following address: ________________________________

________________________________________ within 30 days of commencement date, listed above.


Licensor warrants that it is the owner of rights for the Selection and has the right to grant the permission to republish the materials as specified above.

________________________________________ (User signature)

Name: ________________________________________

Title: ________________________________________

Address: ________________________________________

Date: ________________________________________

Permission Granted By:________________________________________

________________________________________ (Licensor signature)

Name: ________________________________________

Title: ________________________________________

Address: ________________________________________

Date: ________________________________________