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Organization Form A: Image Use Permission Request 1/5 Form A 1/5

rev. Mar. 7, 2013

Image Use Permission Request

Application
Name of organization Address

Date YYYY MM DD (a) Applicants name YOUR NAME YOUR NAME in katakana Address Affiliation Title / Speciality Telephone number with country code Fax number with country code E Email address [Choose one] (1) (2) (b) (c) I am applying to obtain permission to reproduce an image of a work (b), that your organization [Choose one] (1) has used or published (2) holds in its collections, in my publication (c) as detailed below. (b) The name of the image and any other identifying information (where it is published, posted, held, etc.)

[Highly recommended, if possible] A copy of the work has been attached for identification purposes. (c) Details of the planned publication 1. Author YOUR NAME

Organization Form A: Image Use Permission Request 2/5 Form A 2/5

rev. Mar. 7, 2013

2. /() Title of the book, or titles of the paper/article and journal/anthology in which it will be included (in the language of publication) Japanese translation of the above titles 3. Genre(Check appropriate box(es)) Scholarly monograph Textbook Other_________ 4. Publisher Name and contact information of editor 5. Expected date of publication 6. Approximate number of pages 7. Expected readership(Check appropriate box(es)) Students/ Researchers/specialists General public 8. Sales region(Check appropriate box) North America No regional limits 9. Publication format(s)(Check appropriate box(es)) Book Digital publication media Other 10. Number of copies to be published 11. Expected price 12. Image to be used(Check appropriate box(es)) Color B&W Jacket 1 Full-page size 13. Notes[If applicable] likelihood of reprinting or expanded publication etc.

(d) In the event permission is granted (Check appropriate box(es)) 1. I would like to scan the image from the

Organization Form A: Image Use Permission Request 3/5 Form A 3/5

rev. Mar. 7, 2013

following publication TITLE OF PUBLICATION URL WEB ADDRESS I would like to download the image from the above Web page. I would like to request a publication-quality image(Check appropriate box(es)) Color Black and white Digital image Desired file format / Transparency / duplicate Photographic print 2. I would appreciate the image by YYYY MM DD End of Application

Permission
Date (YYYY/MM/DD)

[Date of request] YYYY MM DD (a) YOUR NAME in katakana (b)(c) This is to grant (a) YOUR NAME permission to reproduce an image used/held by our organization (b), in the publication (c), as described above and requested on DATE OF REQUEST . Name of organization Above name in English or romaji Address in romaji Name of relevant department Above name in English or romaji Contact person Above name in romaji Signature of legal representative of organization

Organization Form A: Image Use Permission Request 4/5 Form A 4/5

rev. Mar. 7, 2013

Above name in romaji **********

V The conditions below must be observed. (Check appropriate box(es)) The publication must include that the image is being used with our organizations permission. Please send us _____copies of the publication. Other conditions (This may be in Japanese)

V Image to be used (Check appropriate box(es)) Scan image from the following publication (Specify publication in Japanese and romaji)

URL Download image from the above Web page. A publication-quality image will be provided according to the following conditions Color Black and white Digital image File format Transparency Photographic print

Organization Form A: Image Use Permission Request 5/5 Form A 5/5

rev. Mar. 7, 2013

The image is enclosed. [] ___________ [] Further action is needed to obtain the image; contact the above person with a copy of this permission. Please return the image after use. End of Permission

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