Random House, Inc. Permissions Request Form

Date of Submission: ______________________________

Information Pertaining to Our Book:

Title: ___________________________________________

Author: _________________________________________

Publisher/Imprint: _______________________________

Copyright Year: _________________________________

ISBN: ___________________________________________

Material you want to use (Please specify page number
and/or approximate number of words): ___________________

A photocopy of the material in context must be provided.

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: __________________________________________

Please allow 3-5 weeks for a response.
A self-addressed stamped envelope would be appreciated.