Pfeiffer :: Republication/Electronic Request Form

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	Republication/Electronic Request Form

First Name:

Last Name:

Name of Company or Organization:

Street Address:

City:

State/Province:

Zip/Postal Code:

Country:

Contact Phone Number:

Fax:

E-mail Address:

Your Reference Number (if any):

Wiley product/title from which you'd like to reprint:

Is this title a book or a journal?

If this title is a book, please provide the following:

Book's Primary Author or Editor:

Book's ISBN:

If this title is a journal, please provide the following:

Journal Month:

Journal Year:

Journal Volume:

Journal Issue Number:

Specific pages or range of pages of text and/or figure/table numbers you wish to reproduce:
[If the number of figures exceeds 5 figures and/or 300 words of text per requested work, or if you're adapting (changing) our material, please fax (201-748-6008) or mail (Permissions Dept., John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030) copies of the figures (and your adapted versions if applicable) with this request.]

Maximum print run estimate:

Your Publisher:

Title of Your Work:

Projected Publication Date:

Format of Your Work:

		Print:

		CD-ROM:
		What is the size of the print run (in number of copies)?

		E-Book:
		Reader Type (Adobe Reader):

		WWW:

		What is the url where the material would be located?

		Is the material requested from an adopted textbook used for a college course?

		Is the web site where the material will be posted password protected, or is access to the site limited in any way?

		What is the instructor's or professor's name?

		What is the name and number of the course?

		How many users would have access?


		How long will the material be posted (not to exceed a two year limit)?
		From:		(dd/mm/yyyy)
		To:		(dd/mm/yyyy)

		Intranet:

		What is the url where the material would be located?

		Is the material requested from an adopted textbook used for a college course?

		Is the web site where the material will be posted Password Protected, or is access to the site limited in any way?

		What is the instructor's or professor's name?

		What is the name and number of the course?

		How many users would have access?


		How long will the material be posted?
		From:		(dd/mm/yyyy)
		To:		(dd/mm/yyyy)

		Software Program: (i.e. Powerpoint, database, disk)

		What is the size of the print run (in number of copies)?



	Please indicate any unusual circumstances regarding this request (such as you are the author of the requested material)

	(Please note: Response will be sent via fax or mail, not by e-mail.)

John Wiley & Sons, Inc.
and Wiley-Liss, Inc.
Permissions Department
111 River Street
Hoboken, NJ 07030
USA
0101-201-748-6011 (Telephone)
0101-201-748-6008 (Facsimile)

John Wiley & Sons, Ltd.
Permissions Department
The Atrium
Southern Gate
Chichester
West Sussex PO19 8SQ
United Kingdom
44-1243-770322 (Telephone)
44-1243-770620 (Fascimile)
permreq@wiley.co.uk

Wiley-VCH Publishers, Inc.
Rights and Permissions
P.O. Box 10 11 61
s D-69451, Weinheim
GERMANY
49-6201-606-280 (Telephone)
49-6201-606-215 (Telephone)
49-6201-606-332 (Fascimile)
rights@vchgroup.de

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