PERMISSIONS Pauline Books and Media Permissions Request Form Date of Submission: _______________________________________________

Information Pertaining to Our Book:

Title: ___________________________________________________________

Author: _________________________________________________________

Copyright year: _______________ISBN: _______________________________

Material you want to use (please specify page number and/or approximate number of words): Page numbers: ________________ Word count: ________________________

A photocopy of the material in context must be provided if requesting to publish the material in a new project.

Information Regarding Your Project:

Title: ____________________________________________________________

Author: __________________________________________________________

Publisher: _______________________________________________________

Territory needed: ___________________Print run/circulation:_______________

Price: ________Publication date: _ ____________________________________

Number of pages of your book: _________________________

Format (Hardcover/Softcover/E-book): ___________________

Requester Information:

Name: __________________________________________________________

Position: ________________________________________________________

Company: _______________________________________________________

Address: ________________________________________________________

City: ___________________________________________________________

State: __________________________________________________________

Zip Code: ________________________________________________________

Phone: _________________________________________________________

Fax: ___________________________________________________________

E-mail: __________________________________________________________

If mailing your request, please allow 3-5 weeks for a response. If emailing your request, you may expect a response to your inquiry within 3 business working days. Email to: internationalrights@paulinemedia.com.

A self-addressed stamped envelope would be appreciated.