Author Excerpt Usage Consent Form
Please complete this form to grant permission for the use of your excerpt in a publication or project.
Author's Full Name
*
First Name
Last Name
Author's Email Address
*
example@example.com
Author's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Requester's Full Name or Organization
*
First Name
Last Name
Requester's Email Address
*
example@example.com
Title of the Work Containing the Excerpt
*
Excerpt Text (or upload if lengthy)
*
Upload Excerpt File (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Purpose and Intended Use of the Excerpt
*
Where will the excerpt be used?
*
Book
Website
Magazine/Journal
Presentation
Other
Duration and Territory of Use
How would you like to be acknowledged?
Author's Signature
*
Submit Consent
Submit Consent
Should be Empty: