Permission Request Form
Contact Phone Number:
Galenos product/title from which you'd like to reprint:
Enter the name of the journal which includes the product/title:
Journal Issue Number:
Specific pages or range of pages or total number you wish to copy/reprint
How did you reach the product/title?
Will the material be posted on a website or intranet site?
What is the url where the material would be located?
Is the web site where the material will be posted password protected, or is access to the site limited in any way?
How many users would have access?
Will the reprinted material used for commercial purposes?
IF THE MATERIAL WILL BE POSTED ON A BOOK, PLEASE PROVIDE THE FOLLOWING
Book's Primary Author or Editor:
In-stock Date (if known):
Please indicate any unusual circumstances regarding this request (such as you are the author of the requested material) (Please note: Response will be sent via fax or mail, not by e-mail.)