Date:

To:          [Copyright Holder]

From:      Professor
               Department
               University of Wisconsin-Milwaukee

Re:          Permission to use copyrighted material

I would like your permission, as the holder of the copyright for the material listed below, to allow the material to be copied by the UWM Libraries and made available to students in my class through the Libraries' Reserve Desk.

Only one copy of the work will be made by the library staff.  Access to this copy will be restricted to the UWM community.  The reproduction will faithfully copy the work in its entirety and will include a copyright notice.

Citation of material to be used:

author(s):
title of article/chapter:
journal/book title:
date/volume/edition:
chapter(s)/pages to be scanned:

Thank you for your prompt reply to this request and for assisting in the educational process at the University of Wisconsin-Milwaukee.