Book Permissions Request Form

Books Permission Request Form
Name *

First Name Last Name
Company/Organization *
School, Company, Organization Name
Street Address *
Optional: Address (Floor, Building, Apt)
City *
State or Province *
Postal Code *
Country *
E-mail *
wolterskluwers@email.com
Phone Number *
I am... *
Please describe your role: *
Wolters Kluwer Product Information (Book or Anatomical Charts)
Are you requesting permission from a book or an ACC Chart? *
Number of ACC Charts Requesting *
Anatomical Chart Name *
Anatomical Chart ISBN (13 digit) *
(example: 9781587791000)
Anatomical Chart Name *
Anatomical Chart ISBN (13 digit) *
(example: 9781587791000)
Anatomical Chart Name *
Anatomical Chart ISBN (13 digit) *
(example: 9781587791000)
Anatomical Chart Name *
Anatomical Chart ISBN (13 digit) *
(example: 9781587791000)
Anatomical Chart Name *
Anatomical Chart ISBN (13 digit) *
(example: 9781587791000)
Anatomical Chart Name *
Anatomical Chart ISBN (13 digit) *
(example: 9781587791000)
Author *
Title *
Edition *
ISBN (without dashes) *
I would like to use: *
Content Requested [List the specific figures, tables, or text for permission] *
*Please Note*: We cannot grant permission without this information
Do you have additional permissions to request? *
Additional Permissions Needed
Author *
Title *
Edition *
ISBN (without dashes) *
Put N/A if there is no ISBN
Type of Reuse *
Content Requested [List the specific figures, tables, or text for permission] *
*Please Note*: We cannot grant permission without this information
Author *
Title *
Edition *
ISBN (without dashes) *
Put N/A if there is no ISBN
Type of Reuse *
Content Requested [List the specific figures, tables, or text for permission] *
*Please Note*: We cannot grant permission without this information
Author *
Title *
Edition *
ISBN (without dashes) *
Put N/A if there is no ISBN
Type of Reuse *
Content Requested [List the specific figures, tables, or text for permission] *
*Please Note*: We cannot grant permission without this information
Author *
Title *
Edition *
ISBN (without dashes) *
Put N/A if there is no ISBN
Type of Reuse *
Content Requested [List the specific figures, tables, or text for permission] *
*Please Note*: We cannot grant permission without this information
Are you the author of this original WK material, or requesting on behalf of the original author? *
Is the author a part of the new project? *
Intended Use
How Will Our Content Be Used? *
Book: Author, Title, Edition, Publisher, Publication Date, Price and Page Count.
Journal: Author, Title, Issue, Publisher, Publication Date
CME: Course Name, Dates of the Course, Lecturer/Professor Name, and Number of Particpants for CME
Conference/Meeting: Name of Meeting, Dates for Meeting, and Number Attending/Copies Needed
Course-Pack/Classroom: Course Name, Dates for Course, Teacher/Lecturer Name, and Number of Copies or Students
DVD/CD/USB: Title of DVD or CD and Number of Copies Needed
Government Report: Report Name, How/Where Will it Be Submitted and Number of Copies Needed
Mobile Application: Name of Application, Description of Application and Release Date
Newsmedia: Title of Newspaper/Newsletter, Publisher, Publication Date, and Number of Copies
Photocopy: Number of Copies Needed
Poster: Where Will It Be Displayed, Duration of Posting, and Number of Copies Needed
Thesis/Dissertation: Title of Thesis, Quantity of Copies Needed, and Website(s) Thesis Will Be Posted
TV/Documentary/Film: Name of TV Show/Documentary/Film, How Our Material Will be Used, Broadcast Date and Location.
Website: Website Address, Website Description and Duration of Posting
Please provide description of your proposed use for our material
Please Provide: *
PLEASE NOTE THAT IN ORDER FOR YOUR REQUEST TO BE CONSIDERED:
- Article is required to have been accepted for publication in a journal
- The journal cannot be published under an Open Access License
For the new project, has the article been accepted for publication? *

Yes No
For the new project, will the journal be published under an Open Access (OA) License?

Yes No
Where do you attend university? *
Will the Wolters Kluwer/LWW Content be shown on camera?

Yes No
Will this be posted to your university website? *

Yes No
Is the website password protected *

Yes No
Will the website be password protected *

Yes No
Have the books been adopted for the course? *

Yes No
I am receiving sponsorship *
Additional languages (other than English) *

Yes No
Number of Languages *
Language(s) needed *
(This does not include English which is standard)
Format *

Print and Electronic Print Only Electronic Only
Notes/Comments
**PLEASE NOTE**
Form submitted with incomplete/missing information will delay your permission process.
Thank You.
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