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.