Hirzel: Reprint Permission Request Form

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Reprint Permission Request Form

Personal Info

Title

First Name*

Last Name*

E-mail*

Phone

Position

Institute/Company

Address

Your Publication

I am / we are at present preparing

an article tentatively entitled

to be published in

Journal title

Book title

Publisher

Our Publication

I/we ask you for your permission to reproduce the following text parts / illustrations in our above mentioned article from your publication:

Author

Title

Edition

Journal

Vol.

Figure(s) / table(s) / text quotation(s)

Page

Publisher

Year of publication

Remarks

We herewith conrifm to give the usual source of reference in the credit line.

Captcha*

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