Copyright Permission Request

Permissions Department
Turner White Communications, Inc.
125 Strafford Ave., Suite 220
Wayne, PA 19087
FAX: (610) 975-4564

Date:____________________

Attention: Permissions Department

Our company, ________________________________________, requests your permission to reprint
the following Turner White Communications, Inc. material:

Journal (Circle):  Hospital Physician, Journal of Clinical Outcomes Management, Seminars in Medical Practice

Title of article: _____________________________________________

Author(s): ________________________________________________

Year of Publication:________ Volume/Issue:_________ Page(s):________

Number of copies to be made:_______

Requested material is:
(please select one)

____Table ($200)

____Figure ($200)

____Article

Requested material will be used in:
(please select one)

____Book

____Journal

____Other

___________________________________________________
(specify use)

If permission is granted, the requested material would be used as:

Academic use (Course):___________________________________________

Title of proposed work:___________________________________________

Publisher: ______________________________________________________

Mailing address: _________________________________________________

Contact person and title: __________________________________________

Phone: __________________________ Fax: __________________________

 

Sincerely,