The Undersigned hereby grant(s) permission to ______________________________________________(hereinafter referred to as the "Author"), located at _____________________________________________________, and to the Author's successors and assigns, to use the material specified in this Permission Form in the book titled _________________________________________________ to be published by __________________________________________________________.

This permission is for the following material:

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Nature of material : ________________________________

Source: ________________________________

Exact description of material, including page numbers:

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If published, date of publication: ____________________

Publisher: ___________________________

Author(s): ___________________________

This material may be used in the Author's book and in any future revisions and editions thereof, including nonexclusive world rights in all languages.

It is understood that the grant of this permission shall in no way restrict republication of the material by the Undersigned or others authorized by the Undersigned.

If specified here, the material shall be accompanied on publication by a copyright notice as follows:

(c) by _____________ (author's name) , 19____.

and a credit like as follows: ___________________________________

Other provisions, if any: ____________________________________________

If specified here, the requested rights are not controlled in their entirety by the Undersigned and the following owners must be contacted:

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One copy of this Permission Form shall be returned to the Author and one copy shall be retained by the Undersigned.

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Authorized Signatory Date

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Authorized Signatory Date