Date:     ______________________________________

From:     ______________________________________
                (student's name and address)

To:         ______________________________________
                (copyright holder)

        I request permission to quote/reproduce/modify (circle all that apply) the material described below, on which you hold the copyright, in my master's thesis. The material will be used as a complete unit. Upon acceptance of the thesis, microfilm copies may be published on demand by ProQuest Information and Learning Company.

        If the material is from a journal, I have enclosed a letter from the author of the article giving me his/her permission to reproduce the material.

Description: Author(s) full name(s), title of work, title of journal, edition, series, publisher, date, volume number, page number(s):
 

Signed    ______________________________________

Permission is hereby granted/denied (circle one) for the above named student to include the materials described above in his/her master's thesis and for ProQuest Information and Learning Company to reproduce and sell on demand said thesis on microfilm.

Signed     ______________________________________
                Permissions Editor

Date        ______________________________________
 

For          ______________________________________
                Copyright Holder