This form is to be prepared in duplicate. After completing the section below and signing both copies where indicated, forward them to the publisher who will complete the form and return it to you. If the publisher indicates a payment for the right you request, and if the conditions are agreeable to you, remit the amount to the publisher together with the original copy, which he will have signed, whereupon the agreement will be completed.
To: __________________________ [Name of Publisher]
I (We) wish to procure __________ copies of your copyrighted publication:
by: ____________________________________________________. [Composer]
If it is in print: Please indicate the price per copy here: $________________
If it is out of print: Do you have plans to reprint it? _______________________
If so, when? _______________________________________
At what price per copy? $_____________________________
If there are no plans for reprinting, I (we) request your permission to have a nonexclusive right to reproduce by photocopy ________________ copies for use by my (our) (students, members, congregation, etc.)
The copies will be identical to your publication including the copyright notice. The following will be legibly included on the first page of each copy of our reproduction:
"This reproduction is made with the express consent of __________________________
[Copyright Owner’s Name] in accordance with the provisions of the United States Copyright Law.
"I (We) acknowledge that I (we) am granted no right to sell, loan, or otherwise distribute reproduced copies of the publication other than for the use set down above. No other rights of any kind for any other use are included in this permission.
If permission to make copies can be granted, will you charge a fee? _________________
If so, how much? ________________
If you do not grant the above permission, will you supply me (us) with photocopies?
If so, at what price per copy? $ ________________
Accepted and Agreed to: